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Exit Survey
 
 
First Name
   
Last Name
   
Address
   
City
   
State
   
Zip
   
Phone
   
Mobile
   
Email
   
 
 
 
Which Medicine you use or Surgery you had done?
 
Mesh Surgery
 
Bladder Sling Surgery
 
Xarelto Blood thinner
 
Testosterone Therapy (Low-T)
 
IVC (inferior vena cava filters)
 
Invokana
 
Benicar
 
Anti depressant
 
Zofran
 
Lung Cancer
 
Power Morcellators
 
Other
 

 
 
 
Have you faced any side effects or complications?
 
Yes
 
No
 
 
 
Describe your side effects / complications or comments in the box.
   
 
 
 
Are you currently represented by an Attorney or LawFirm regarding this Matter?
 
Yes
 
No
 
 
 
Would you be interested in speaking with an Attorney for a free case review?
 
Yes
 
No
 
 
 
Best Time to contact
 
Morning
 
Afternoon
 
Evening
 
Anytime