Client’s name, address, phone number, email, DOB, marital status and referral source information.

When was the initial procedure to implant the IVC filter?

Why did you have the IVC filter implanted? (to reduce the risk of deep vein thrombosis – “DVT’s- or other blood clots related to surgery? Prior history of blood clots? Unable to receive anti-coagulation drug therapy/blood thinners? Other?)

Who performed the implant surgery and where (name and address of dr and hospital)?

Do you have the product name or manufacturer name for the IVC filter used? Yes or No.

If yes, which of the following products was it?

  • Ask if it was one of the following IVC filters implanted:
  • Bard Recovery Vena Cava Filter
  • Bard G2 Vena Cava Filter
  • Bard G2 Express (G2X)
  • Bard Eclipse Vena Cava Filter
  • Bard Meridian Vena Cava Filter
  • Bard Denali Vena Cava Filter
  • Cook Gunther Tulip Vena Cava Filter
  • Cook Celect Vena Cava Filter
  • Other? ______(secure name or information they know)

When did you begin to experience problems as a result of the IVC filter? (date)

What were the problems/injury sustained? Specify, as well, any of the following apply:

  • Stroke
  • Deep Vein Thrombosis (DVT)
  • Bleeding
  • Pain (describe)
  • IVC Filter Device migration
  • IVC Device perforation of a bodily organ (what organ was perforated?)
  • IVC Filter Device fracture
  • Movement of the entire IVC Filter or Filter fragments move to the heart or lungs. This is called detached device components or device embolization
  • IVC Filter revision surgery (to remove the filter). Was the IVC Filter irretrievable?
  • Death (if so, please secure date of death):

Are you currently experiencing symptoms related to the IVC Filter? If so, what are the symptoms?

Has the IVC Filter been removed in whole or in part? If so, what was the date of removal and medical provider information for this procedure?

Has any doctor related your problems as related/caused by the IVC Filter? If so, provide this doctor name and address who related this and when he/she gave that opinion.

Do you or did you have any other lawyer review this matter for you?

The initial implant surgical records will help specify the make and model of IVC Filter the patient has. Do you have the medical records for the implant?

Cohen, Placitella & Roth, P.C.

888-375-7600

Philadelphia, PA Red Bank NJ