Get Salter Ferguson Hip Implant Questionnaire 2020-2026

Filling out the Salter Ferguson Hip Implant Questionnaire can help facilitate a thorough evaluation of your injury. This guide provides detailed steps to assist you in completing the form accurately and efficiently.

Follow the steps to successfully complete the questionnaire.

1. Press the ‘Get Form’ button to access the Salter Ferguson Hip Implant Questionnaire. This will allow you to open the document online.
2. Begin by filling out Box 1, which contains the injured person's information. Include their full name, address, date of birth, social security number, and contact numbers. Make sure to provide their email and the county as well.
3. Move to Box 1.e, and list three individuals or places that can confirm the injured person's location. Specify each person's name, relationship, and two contact numbers.
4. Indicate in Box 1.f whether you are completing the form for yourself or someone else. If for another person, proceed to Box 2.
5. In Box 2, confirm whether the person completing the form is the injured person (2.a). If not, provide your relationship to the injured person, and fill in your name and contact details in subsequent fields.
6. Proceed to Box 3, where you will enter detailed information about the hip implant. Provide the date of the first total hip implant and whether it was for the left or right hip. Note any revision surgeries and additional hip implants, if applicable.
7. In Box 4, indicate whether you have received any recall notifications regarding the hip implant. If yes, detail the manufacturer and include any implant cards you may possess.
8. Box 5 requires you to specify the insurance provider that paid for the total hip implant device and note if any funds have been reimbursed.
9. Fill out Box 6 with information on each hip surgery, including dates, sides, physician names, and hospital addresses.
10. In Box 7, answer questions about legal representation and provide additional information that may be relevant to your claim.
11. Once you have completed all boxes, review the information for accuracy. After verifying the details, you can save changes, download a copy, print the document, or share it as needed.

Complete your Salter Ferguson Hip Implant Questionnaire online today to ensure your case is accurately evaluated.