Name:
Address:
      City:
    State:
       Zip:
 Phone:
     Fax:
 E-Mail:
Firm's Name:
   Profession:

Type of Membership that you are applying for: Platinum Gold Silver Consumer

Injured Consumer please also fill in section B
Breast Implants patients please also fill in section C

B) Type of Injury:
Medical Device
Device Type:
Prescription Drug
Name of Drug:
Environmental Injury
Type of Injury:
Chemical Injury
Name of Chemical:

C) Breast Implant Info:
Year Implanted:
Year Explanted:
If you remain implanted check here:
Name of Manufacturer If Known:
Type of Implant: N/A Silicone Saline Double Lumen Expander
Were your implants ruptured: No Yes
Was you claim filed in a timely manner: No Yes
If no: Is your claim filed at all? No Yes