Mark & Associates, P.C. Attorneys At Law

* First Name

* Last Name

* Home Phone

Cell Phone

* E-mail

Address

Address 2

City

State ALABAMAALASKAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREDISTRICT OF COLUMBIAFLORIDAGEORGIAHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTAOHIOOKLAHOMAOREGONPENNSYLVANIAPUERTO RICORHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASU.S. VIRGIN ISLANDSUTAHVERMONTVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMING

Zip

Date of Birth of Injured Person (mm/dd/yyyy):

Date Defibrillator or Pacemaker was Implanted

Name of Defibrillator or Pacemaker that was Implanted

Have you ever experienced multiple shocks? Yes No

If yes, please describe shocks and any associated problems

Has your pacemaker or defibrillator ever failed to work? Yes No

Was your pacemaker/defibrillator or lead REPLACED?

Date New Lead was Implanted (mm/dd/yyyy)

Other information

I agree to the legal disclaimer.