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This questionnaire is intended to provide the basic information necessary to evaluate your claim for compensation arising from a person's injury following a Cypher™ Coronary Stent Procedure. Please complete it to the best of your ability with as much detail as possible. Any information you submit will be kept strictly confidential.

Please complete the form and click the "submit" button at the end to send the information to us electronically. Note that information in fields marked with an asterisk must be completed in order for this form to be processed.

You may also complete the form, print out and mail to:
Joseph Santoli • 340 Devon Court
Ridgewood NJ 07450-1810
Toll-Free 1-800-279-6996

Cypher™ Coronary Stent Claim History Questionnaire for an Individual

* Your Name:
* Your Telephone Number:
* Your Mailing Address:
Your Fax Number:
* Your E-mail Address:


* Brand of Coronary Stent implanted:Choice
Cypher™ Stent
Don't Know
Other:
If not known, please ask your medical insurance company or payment guarantor for name of stent
* What was the original diagnosis resulting in your stent procedure?
* Date of procedure
* Where was the stent procedure performed?
* Name of doctor who performed the stent procedure
* Address of doctor who performed the stent procedure
*  Did you experience any of the following after the stent procedure?
  Yes     No   
Thrombosis (clotting)
Heart Attack
Pain
Rash
Respiratory Alterations
Hives
Itching
Fever
Blood Pressure Changes
Other

Did you have additional procedures following the initial stent procedure?

  Yes     No   
Open Heart Surgery
Other Surgery
Other

* Name of doctor who performed additional procedures
* Address of Doctor

*  Has anyone filed any civil complaint for damages related to these facts? YesNo

*  If you had any significant health problems at time of coronary stent procedure, please explain them here:

If there is something you wish to add, do it here: