Kugel Mesh Inquiry

Do you have a hernia mesh lawsuit? Find out by answering this questionnaire. All information is confidential.

PERSONAL INFORMATION

First Name:

Last Name:

E-mail Address:

Address:

City:

State:

Zipcode:

Phone:

() - ext.

SURGERY INFORMATION

Check all you have experienced:

Persistent Surgical Site Drainage
Bowel Paralysis
Severe Persistent Abdominal Pain
Abdominal Tenderness
Distended Abdomen
Fluid in Abdomen
Abdominal Abscess Formation
Intestinal or Bowel Perforation

Internal Fistulas
External Fistulas
Pelvic Inflammatory Disease
Peritonitis
Sepsis
Corrective Surgery

Date of surgery:

Manufacturer of the Mesh used in your surgery:

Model of the Mesh used in your surgery:

Please describe problems you have had:

Please describe what your doctor has told you about these problems:

Did the memory ring in the patch break?

Yes No

Did the patch/ring casue a perforation?

Yes No

Was the memory ring and patch removed?

Yes No

Date Removed:

What has your doctor recommended?

Questions/Comments:

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