Smith & Nephew Hip Implant Questionnaire

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Ashley Wood
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1 Smith & Nephew Hip Implant Questionnaire If you (or a loved one) have had difficulties with a SMITH & NEPHEW HIP IMPLANT and want to discuss possible legal action, please fill out this form: PART ONE: INSTRUCTIONS The following questions are designed to help determine if you (or your loved one) have a potential claim related to a defective SMITH AND NEPHEW hip implant. All of these questions are important. I realize that you may not know the answers to all questions. Please answer all questions to the best of your ability. You may submit this Questionnaire in one of three ways: 1. Online: Please fill out the form at or 2. By Mail: If you prefer, you may print this questionnaire and mail it to: Kip Petroff Law Office 4264 West Lovers Lane Dallas, Texas Phone: By Fax: Fax it to us at Response Time: I try to respond promptly to all Questionnaires from prospective clients, but I sometimes cannot meet that goal. Please make sure to follow up if you haven't heard back within three business days of submitting this Questionnaire. Smith & Nephew Hip Implant Questionnaire Page 1 of 7

All of these questions are important. I realize that you may not know the answers to all questions. Please answer all questions to the best of your ability.

2 PART TWO: PERSONAL BACKGROUND INFORMATION First Name (required): Last Name (required) : Address: Mailing Address: City: State: Zip: Phone: Are you a former client of Kip Petroff in Dallas, Texas? (Required) If you answered "YES" above, please also provide the address where you lived when you were a client and provide the name or names you used when you were a client: Smith & Nephew Hip Implant Questionnaire Page 2 of 7

(Required) If you answered "YES" above, please also provide the address where you lived when you were a

3 PART THREE: HIP IMPLANT INJURY INFORMATION Please provide the following information regarding any SMITH & NEPHEW hip implant you have had implanted in your body. Most people have received two hip implants in two separate surgeries performed by the same doctor, and this questionnaire is designed with that in mind. Try to provide information about each surgery based on whether it is surgery # 1, surgery # 2, etc. There is plenty of room at the end to ask questions or provide additional details. I will call you or you soon to discuss this questionnaire after you have submitted it. Smith & nephew hip implant surgery # 1: 1(a). Please provide the following information about implant surgery # 1: Date of implant surgery # 1: Location of hospital: Type of implant: Name of surgeon(s) implanting device(s) # 1: 1(b). Is device #1 still in your body? 1(c). If you answered "NO" to question 1(b) above, please answer the following questions about the removal of device # 1 from your body: Date the device was removed: The name and location of the hospital where it was removed: The location (if known) of the removed device: The name of the surgeon(s) removing the device: Smith & Nephew Hip Implant Questionnaire Page 3 of 7

Try to provide information about each surgery based on whether it is surgery # 1, surgery # 2, etc. There is plenty of room at the end to ask questions or provide additional details.

4 1(d). Have you had device # 1 replaced with another implant? 1(e). If you answered "YES" to question 1d above, please identify the type of replacement implant for Device # 1, including the name of the manufacturer and model of the replacement implant: If you answered "YES" to question 1(d), please also answer questions 2(a) 2(e). If you answered NO to questions 1(d), please skip to question 4. Smith & Nephew hip implant surgery # 2 (if applicable): 2(a). Please provide the following information about implant surgery # 2: Date of implant surgery # 2, if any: Location of hospital: Type of implant: Name of surgeon(s) implanting device(s) # 2: 2(b). Is device #2 still in your body? 2(c). If you answered "NO" to question 2b above, please answer the following questions about the removal of device # 2 from your body: Date the device was removed: The name and location of the hospital where it was removed: The location (if known) of the removed device: The name of the surgeon(s) removing the device: Smith & Nephew Hip Implant Questionnaire Page 4 of 7

answered "YES" to question 1(d), please also answer questions 2(a) 2(e). If you answered NO to questions 1(d), please skip to question 4. Smith & Nephew hip implant surgery # 2 (if applicable): 2(a).

5 2(d). Have you had device # 2 replaced with another implant? 2(e). If you answered "YES" to question 2(d) above, please identify the type of replacement implant for Device # 2, including the name of the manufacturer and model of the replacement implant: If you answered "YES" to question 2(d), please also answer questions 3(a) 3(e). If you answered NO to question 2(d), please skip to question 4. Smith & Nephew hip implant surgery # 3 (if applicable): 3(a). Please provide the following information about implant surgery # 3: Date of implant surgery # 3, if any: Location of hospital: Type of implant: Name of surgeon(s) implanting device(s) # 3: 3(b). Is device #3 still in your body? 3(c). If you answered "NO" to question 3(b) above, please answer the following questions about the removal of device # 3 from your body: Date the device was removed: The name and location of the hospital where it was removed: The location (if known) of the removed device: Smith & Nephew Hip Implant Questionnaire Page 5 of 7

answered "YES" to question 2(d), please also answer questions 3(a) 3(e). If you answered NO to question 2(d), please skip to question 4. Smith & Nephew hip implant surgery # 3 (if applicable): 3(a).

6 The name of the surgeon(s) removing the device: 3(d). Have you had device # 3 replaced with another implant? 3(e). If you answered "YES" to question 3d above, please identify the type of replacement implant for Device # 3, including the name of the manufacturer and model of the replacement implant: PART FOUR: MEDICAL HISTORY QUESTIONS 4(a). Is device # 1, or device # 2, or device # 3, still in your body? 4(b). If you answered "YES" to the above question, please state whether you are having problems with it, and if so, what are your plans for removing it? _ Smith & Nephew Hip Implant Questionnaire Page 6 of 7

model of the replacement implant: PART FOUR: MEDICAL HISTORY QUESTIONS 4(a). Is device # 1, or device # 2, or device # 3, still in your body? 4(b).

7 PART FIVE: LAWSUIT HISTORY 5(a). Has a lawsuit already been filed as a result of any of your implant surgeries? 5(b). If you answered "YES" to the above question, please provide the name and number of the case along with its current status and the name and phone number of your attorney, if any. I will not be able to speak with you about your case if you have an attorney. PART SIX: CONCLUSION I realize that you may want to tell me something about your claim that may not have been asked above. You can use the space below for that purpose. Thank you for your interest in me possibly representing you in your potential hip implant claim. Please type your comments and/or questions below: Smith & Nephew Hip Implant Questionnaire Page 7 of 7

I will not be able to speak with you about your case if you have an attorney.

WHAT YOU SHOULD EXPECT FROM YOUR MENTAL HEALTH COURT-APPOINTED ATTORNEY

2222 West Braker Lane Austin, Texas 78758 MAIN OFFICE 512.454.4816 TOLL-FREE 800.315.3876 FAX 512.323.0902 WHAT YOU SHOULD EXPECT FROM YOUR MENTAL HEALTH COURT-APPOINTED ATTORNEY You should know the following