Sample Case Screening Form for Biomedical Tissue Lawsuit

HUMAN TISSUE CASE INTAKE

1. Client Name:
Address:

Telephone:

E-Mail Address:

Date of Birth:

Social Security No.:

2. Source of contact (lawyer referral, newspaper ad - what paper??):

3. Type of Implant (Bone, Skin, Tooth, etc.)

4. Was a notice received from a doctor or hospital?
YES NO
(Please supply us with copy as soon as possible.)

5. If yes, did you receive a letter from the distributor?
YES NO

6. Did you receive a phone call from your doctor advising you?
YES NO
Describe the call:



7. Name of doctor(s) (surgeon and cardiologist) who implanted the product:



Name of hospital where surgery was performed:

Current physicians (if different from above):

8. Obtain brief medical history leading to implant, and following implant:

9. Have you been tested for HIV, hepatitis and other infectious diseases?
YES NO
If yes, results:


If yes, who paid for tests?


If no, do you plan on being tested?

10. Obtain brief work history (current employer and annual wages):


11. Any additional information and/or comments:






Name Of Person Completing Intake Form Date