PURPOSE: The purpose of this confidential questionnaire is to gather essential information about your experience with Essure, as well as the resulting problems and injuries. Your provided information will allow us to adequately investigate your potential claim, and we cannot move forward with your potential claim until we receive your information. Please fill out this questionnaire to the best of your abilities and submit it as soon as possible.
INSTRUCTIONS: Not every question will apply to you and there is likely more space than you will need. If the question doesn’t directly apply to you, then please answer it as fully and accurately as you can. You may need to look at your medical or pharmacy records, look up a doctor or pharmacy on the internet, or even call one of your doctors or healthcare providers to get information.