PainPumpClaims.com
Get Started: Free Case Review
Please be sure to fill out this form to the best of your knowlegde. You will be contacted by one of our representatives to review your situation.
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STEP 1
Date of your surgery
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Month
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Day
Year
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Hour
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Minutes
AM
PM
AM/PM Option
Did you have surgery on any of the following?
Left Shoulder
Right Shoulder
Left Knee
Right Knee
Other
If Other, Please Explain
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STEP 2
Who is the manufacturer of your pain pump or what type of pain pump is it?
Did you experience any of the following problems after having the pain pump:
Increase Pain
Loss of Range of Motion
Clicking
Trouble Sleeping Due to Pain
Increase Stiffness
Loss of Strength
Popping or Grinding
Numbness/Tingling in arm or hand
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STEP 3
When did you first learn that the pain pump may have caused you injury?
Have you been diagnosed with any of these conditions since your surgery?
Loss of cartilage
Please Select
Yes
No
Chondrolysis (progressive destruction of articular cartilage)
Please Select
Yes
No
Loss of joint space in your shoulder joint
Please Select
Yes
No
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FINAL STEP
Name:
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Address
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City, State, Zip
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Phone:
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E-mail Address
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Please provide us with any additional information or concerns that you may have:
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Thank You
To speak with a representative NOW contact us toll free 877-544-5323
www.PainPumpClaims.com
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