* First Name 

   * Last Name 

   * Email 

   * Phone 

Cell Phone 

What medical condition prompted the use of the device?

Date the device was implanted:

Do you have a Bjork Shiley Convexo-Concave Heart Valve implanted in you?Yes
No

If yes, has the Bjork Shiley Convexo-Concave Heart Valve fractured?Yes
No

Is the device still implanted?Yes
No

If no, please provide the date and reason the device was removed:

Please describe any problems or injuries caused by the product:

No Yes, I agree to the Parker Waichman LLP disclaimers. Click here to review.

Yes, I would like to receive the Parker Waichman LLP monthly newsletter, InjuryAlert.