TIVAD / Port Catheter - Lawsuit
First Name
First Name
Last Name
Last Name
Email
Email
Phone
Phone
Did your port catheter fracture, crack or migrate?
Yes
No
Did the person with the implant experience an infection or death?
Infection
Death
Other
Did you or your loved one have a PowerPort, Port-a-Cath or Chemo Port implanted?
Yes
No
What was the reason the port was implanted?
Did the catheter or implanted port:
Upload gov.id proof (.png, .jpg, .pdf)
Upload gov.id proof
Comments
Comments
By clicking the "SUBMIT" button below, I affirm that I am 13 years of age or older and provide my express written consent to receive autodialed and/or prerecorded telemarketing calls and text messages from
Lawsuit Support
at the telephone number I provided above, including my wireless number, if applicable. I understand that my consent is not a condition of service and that I may revoke my consent at any time by following the opt-out instructions provided in the communications. I have also read and agree to the
Privacy Policy
Submit
Back
