* First Name 

   * Last Name 

   * Email 

   * Phone 

Cell Phone 

Date of bypass surgery: 

Is the device still implanted?Yes
No

What medical condition prompted the use of the device?

Do you know that the St. Jude Symmetry Aortic Connector was used in your surgery?Yes
No

Did the Symmetry Connector cause any of the following?Death
Heart Attack
Respiratory Failure
Valve Leakage
Additional Surgery
Other

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.