Toxic Discovery - Breast Implant Injury Info. Request Form
Do you believe you have been injured by breast implants and are unrepresented by a lawyer?
If you would like to know what Breast Implant Information rights you are entitled to,
at no cost, please fill out the following form. All Information will remain CONFIDENTIAL.

INFORMATION ABOUT YOU:
NAME:

 
ADDRESS:

 
PHONE NUMBER:

 

FAX NUMBER:

 



E-MAIL:

DOB:   


Do You Have Insurance? 

Did you have children born to you while implanted: 





BREAST IMPLANT QUESTIONS:
Approximate Date of 1st Breast Implant Surgery:

 
Brand Name of 1st breast implant

 
Implant Model Number :

 
Implant Lot Number:

 
Do you have "Proof" of the brand of implant you received?

 
If so, what type of proof?
(copy of surgery report that lists brand, letter from doctor, etc.)

 
Have one or more of your implants been removed?

 
Date Implant Removed

 
Did you receive new implants?

 
If so, what was brand of implant?

 
"Do you have proof of this implant?"

 
Have any of your implants ruptured?

 
If so, what Implant Brand Ruptured?

 
List other implant surgeries if applicable and the brand of implant.

Do You Remain Implanted but need to have your implants removed? 

Have you registered with the earlier MDL-926 Class Action?

 
If so, did you receive any money and how much?

 
Have you registered with the Dow Corning Class Action?

 
Do you have an existing attorney?:

 
Have you noticed any of the symptoms listed on the right, after you received your breast implants? 

Check all that apply:
Arthritis
Breast Deformity
Chills/Sweats
Depression
Fever
Hair Loss
Headaches
Joint Pain
Low Disease Resistance
Memory Loss
Muscle Weakness
Weight Gain
Weight Loss
None
Have you ever been treated for any of the above?:
Are you having any unexplained symptoms that you are concerned about?

Any other information you would like to tell me that you feel is important?

Please contact me as soon as possible regarding this matter.

Upon submitting this form, you certify that all of the information given
is true and correct to the best of your knowledge.
All information will remain CONFIDENTIAL.

* PLEASE hit the SUBMIT button ONE TIME only *