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Wais and Vogelstein - baltimore attornerys at law
Call 1-877-STENT-99 for more information
First Name: Middle Name: Last Name:
Date of Birth
(mm/dd/yyyy):		 Age: M / F
Address:
Home Phone: Work Phone: Cell Phone:
Email:

POTENTIAL CLAIM INFORMATION
Date Hospital where Stent Performed City, State Doctor
If procedure performed at St. Joseph Hospital in MD, did client receive a letter? Y / N
Do you have any medical records from the procedure(s)?
Describe complaints, problems or symptoms presented treating cardiologist:
Name of doctor who referred you for the cardiac catheterization:
List all medications prescribed to you following the stent procedure:
How long have you been told you will have to take these medications:
Have you had any of the following complications from the stent procedure:
  YES NO
Chest Pains
Pain or Tenderness in chest where stent inserted
Chills
Fever
Pain or discoloration in the leg
Shaking
Allergic reaction to iodine-based dye
Kidney failure
Arrhythmias (heart rate disorder)
Heart attack / Stroke (when?)
Ruptured artery (dissection)
Blood clots
General Health History
Have you been diagnosed with any of the following:
 YesNoIf yes, when diagnosed?
Congestive Heart Failure
Cancer
Diabetes
High Blood Pressure
High Cholesterol
Stroke
Heart Attack
Other

DEATH OF LOVED ONE OR FAMILY MEMBER

(Only fill out if you believe a loved one or family member died as a result of a stent)
Date of Death: Cause of Death:
Surviving spouse/children
Name Location: City, State Relationship
 
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