Drugs and Medical Devices Center

Medical Device Product Liability Case - Intake Form

Name

Email Address

Phone Number

What is the name of the medical device you were using?

Who prescribed the device?

For what purpose or medical condition was it prescribed?

Was the device accomplishing that purpose?
Yes  No 

Who was monitoring your condition while you were using the device?

Where did you acquire the device?

Did anyone provide you with instructions regarding the device?
Yes  No 

Were you using the device properly when it caused you harm?
Yes  No 

How did the device injure you?

Was the device ever repaired? When and by whom? Describe the repair.

Was the device ever altered? When and by whom? Describe the alteration.

When did you first seek medical care for the injury caused by the device?

What is the current status of the injury caused by the device? Prognosis?

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