* First Name 

   * Last Name 

   * Email 

   * Phone 

Cell Phone 

What medical condition prompted the use of the device?

Date Dialysis treatment started:

Is Dialysis treatment still underway?Yes
No

If no, date Dialysis treatment ended:

Is Baxter International the manufacturer of the Dialysis Blood Filter?Yes
No
Don't know

Please describe any problems or injuries caused by the product:

Date adverse symptoms or injuries were noticed:

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.