Smith & Nephew Hip Implant Questionnaire

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PART ONE: PERSONAL BACKGROUND INFORMATION

First Name (required):

Last Name (required):

Your Date of Birth (required):

Your Email (required):

Please Retype Your Email (required):

Alternate Email Address (optional) Please list an additional e-mail address that can be used if an email to the above address fails to work after multiple attempts:

Phone (required):

Address:

City:

State:

Zip:

Are you a former client of Petroff & Associates or Kip Petroff in Dallas, Texas? *(required):

YesNoDon't KnowNot Answered

*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:

PART TWO: HIP IMPLANT SURGERY INFORMATION

Please provide the following information regarding any hip implant surgeries you may have had.

If you have had any surgeries on your RIGHT hip, please list, in chronological order, when and what you have had done to your right hip:

SURGERIES ON RIGHT HIP:

If you have had any surgeries on your LEFT hip, please list, in chronological order, when and what you have had done to your left hip:

SURGERIES ON LEFT HIP:

PART THREE: CURRENT PHYSICAL CONDITION

Please briefly describe your physical condition at this time, including a description of any physical problems associated with your hip implants:

PART FOUR: CONCLUSION

COMMENTS/QUESTIONS:

You can use the space below to explain something about your hip implants or related information that may not have been asked above. You can use the space below for that purpose. Thank you for your interest in Kip Petroff possibly representing you in your potential Smith & Nephew hip implant claim.

Please type your comments and/or questions below:

Please enter below the characters you see above (required):

Please ensure that your e-mail address and phone number are correctly entered above, so that Kip may contact you.

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