March 13, 2010
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Cataract Implant Intake

Please fill out the form below to have your case evaluated. Provide as much information as possible to speed the processing of your inquiry.

* Name


* Address (City, State, Zip)


Date of Birth


* Phone Number


* Email


If you are completing this questionnaire on behalf of a deceased person: Name of person on behalf of whom you are completeing


Your relationship with the decedent


Date of Birth of decedent


Date of death, if applicable


Did you have an Ophthalmic Innovations International AQUA SENSE intraocular lens implanted?
Yes
No
I don't know

If Yes, Date of surgery


For what condition or why did you undergo the surgery?


What hospital was this performed at?


Do you have records for original implantation surgery?


How is it you know that an AQUA SENSE lens was implanted?


What is the name and address of the surgeon who performed the surgery implanting the AQUA SENSE lens?


What did the doctor(s) tell you about the AQUA SENSE lens or why he or she was using this lens? Please explain in detail what your doctor told you and what side effects, if any, did he or she tell you about?


Have you experienced any other physical problems that you relate or associate the implantation of the AQUA SENSE lens?


If so, (1) when did you first begin having these problems? (2) Are you still having these problems? (3) Has the lens been explanted or surgically removed and if so on what date? (4) Please identify the name and address of the doctor who has been treating you, and, if the lens has been surgically removed, the doctor who performed the surgery and the hospital where the surgery was performed. (5) Did you experience any side effects from the surgery removing the lens?


What else would you like to tell us about how this AQUA SENSE lens has affected your life?


Are you suffering now or have you suffered from any other serious health problems or diseases?




Sending this message does not create an attorney-client relationship, which can be done only after personal consultation and with a written retainer agreement.
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