Sulzer Orthopedic Hip Implant Claim Questionnaire

This questionnaire is intended to provide the basic information necessary to evaluate your claim for compensation arising from a Sulzer Hip Implant. 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 • 615 Franklin Turnpike • Ridgewood NJ 07450-1929
or fax toll-free to: 1-877-926-9210

Sulzer Orthopedic Hip Implant Claim Questionnaire

* Your Name:
* Social Security Number:
* Age:
* Birthdate:
* Mailing Address:


* Telephone Number:
* E-mail Address:

* What was the original reason that you underwent hip replacement surgery?

* Name of doctor who performed hip replacement surgery for you:

* Address of doctor who performed hip replacement surgery for you:

* Date of Hip Replacement Surgery:

* What is the brand name of your hip implant?:

* Have you been experiencing any pain or discomfort since having hip replacement surgery?

Yes No

Inner thigh pain

Groin pain

Pain when arising from seated position

Pain when bearing weight on hip

Other (describe below)

Yes No

Have you had additional hip replacement surgery to remove your original hip implant?

* If yes, list the date of your second hip replacement surgery:

Name of doctor who performed second hip replacement surgery for you:

Address of doctor who performed second hip replacement surgery for you:

Yes No

Have you received a recall notice or other notification regarding the recall of your hip replacement from Sulzer Orthopedics or your doctor?

(If yes, after submitting this form, please fax the notice confidentially to this office at 877-926-9210)

©2000 Joseph R. Santoli, Esq.
615 Franklin Turnpike
Ridgewood NJ 07450-1929
Toll-Free (877) 926-9202 • Phone (201) 444-2888 • Toll-Free Fax (877) 926-9210