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Name:

Phone:

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E-mail:

State:

Surgery Date:

Type of Surgery:

vertebroplasty
kyphoplasty

spineoplasty

Please describe injuries caused by Optimesh surgery:

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First Name:
Last Name:
E-mail Address:
Address:

City:
State:
Zipcode:
Phone:	-
INCIDENT INFORMATION
Date of Surgery:
Type of Surgery:
vertebroplasty kyphoplasty spineoplasty
Name of Hospital / Surgeon:

What problems were caused by the Optimesh?:
Death Cardiac arrest Cement pulmonary embolism Paralysis from cement intrusion into the spinal canal Pedicle fracture Other
Please describe injuries caused by Optimesh surgery: