Allergan Update Questionnaire - Hilliard Martinez Gonzales LLP

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Case ID

First Name

Last Name

Do you have any medical updates to report?

We are updating our records in preparation for discovery requests from Allergan. Please assist us by answering the following questions:

Are you currently employed?

If yes, name of employer and title

If no, last date of employment and reason for leaving

Please provide the name of any hospitals at which you have received treatment during the last 10 years.

Please provide the names of your primary health care providers during the last 10 years

Please provide the names of any plastic surgeons that have provided medical care to you during the last 10 years

Please provide the names of any oncologists who have provided medical care to you during the last 10 years

Please provide the names and specialties of any other healthcare providers who have treated you concerning breast or breast implant-related issues during the last 10 years

Do you currently use tobacco products?

If yes, what type of tobacco products?

If no, have you used tobacco products in the past?

If yes, when did you stop using tobacco products?

Have you posted on Facebook or any other social media sites about your breast implants, your injuries, or the recall?

If yes, on what site(s) did you post to?

What social media sites are you still active on?

In the past 10 years have you been convicted of a felony or crime involving dishonesty?

If yes, please the details of the felony or crime

Have you ever signed a release of claims or warranty paperwork from Allergan?

Do you recall seeing advertisements for Allergan breast implants before you received the textured implants?

If yes, do you have any pamphlets or other materials about the textured implants?

If no, what do you recall about the advertisements?

EspaÑol | Referrals

Call Now: (361) 882-1612 | Toll Free: 1 (800) 334-3298 | Directions

PRACTICE AREAS
ABOUT
NEWS
- Events
ATTORNEYS
CAREERS
RESOURCES
- Privacy Policy
- Terms and Conditions
BLOG
- HMG Spotlight
- HMG Events
CONTACT
- Give Us Feedback