Kip Petroff is now accepting Smith & Nephew hip implant cases. 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:

INSTRUCTIONS:

The following questions are designed to help determine if you (or your loved one) have a potential claim related to a defective Smith & Nephew hip implant.

You may submit this Questionnaire in one of two ways:

1. Online:

Please fill out the form below and hit the “Send” button at the bottom, or

2. By Mail:

If you prefer, you may print this questionnaire in PDF format and mail the completed form to:

Kip Petroff Attorney At Law
10440 N. Central Expressway, Suite 1540
Dallas, Texas 75231

Response Time: Kip tries to respond promptly to all Questionnaires from prospective clients, but sometimes that is not possible. Please make sure to follow up if you haven’t heard back within three business days of submitting this Questionnaire.

 



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):

 

*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:


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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.

By submitting this Hip Implant Questionnaire, you certify that you agree to the Terms of Use (TOU)  and wish to be contacted regarding your inquiry.  Please click below to open the TOU.

Terms of Use (TOU)

Please Read Our Terms of Use For This Web Site:

Welcome to the web site of Kip Petroff, Attorney at Law. The Terms and Conditions for use of this site are written below. Please read them carefully. By using this site, you acknowledge that you have both read and accepted these terms and conditions. If you do not agree with these terms and conditions, do not use this site.

The information contained on this web site presents general information about Kip Petroff and is not intended to constitute legal advice. Any person viewing or receiving information from this web site should not act or refrain from acting on the basis of any such information without first seeking appropriate legal advice from an attorney.

Kip Petroff invites you to contact him and welcomes your calls, letters and emails. Please realize that merely contacting Kip does not create an attorney-client relationship. Therefore, please refrain from sending any confidential information until such time as an attorney-client relationship has been established. An attorney-client relationship can only be created by a written, signed fee agreement entered into with an attorney.  You do not have an attorney-client relationship with Kip Petroff until you have a written fee agreement with him that he has signed.

(You can also view the TOU in a new window by clicking here)