Title
Mr. Mrs. Ms. Miss Mr. & Mrs. Dr.

* First Name

* Last Name

* Email Address

* Phone Number

Cell Phone Number

Office Phone Number

Street Address

Apartment/Suite

City

State
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Zip Code

Please provide the best method and times to contact you:

Date of birth of person injured
(mm-dd-yyyy):

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 device:

Other Info:

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