DATE: ____________________

PERSONAL INFORMATION

First Name ___________________ MI ______ Last Name __________________________________________

List name(s), aliases, etc. you have used (for medical records purposes:

_________________________________________________________________________________________

Social Security No. _________-_______-_________ D.O.B. ______________

Driver’s License No. ______________________ State __________________

Spouse First Name _______________________ MI _______ Spouse Last Name ________________________

Social Security No. _____-___-_______ D.O.B. ______________________

Driver’s License No. __________________ State _________________

Residence Address _______________________________________________________________________

City/State_______________________________ Zip ____________

Mailing Address _______________________________________________________________________

City/State _______________________________ Zip ___________

Home Phone (____) _______________ Business Phone (____) ______________

Spouse Business Phone (____) ___________________________

Fax Number (____) ___________________

Other (i.e., e-mail address) ______________________________________________

Height ________________________ Weight __________________

Are you covered by medical insurance? ____________________________

Policy No. _________________________________________________

Name of Provider __________________________________________

Have you had more than one implantation? Yes / No If yes, number: ____________

Surgery / /

Surgeon’s Name

Have you ever been treated for any of the above? Yes / No If so, what was the diagnosis as to each problem?

__________________________________________________________________________________________________________________________

Please use a separate sheet of paper if necessary to give a full explanation.

List your primary care physician(s) (including address and phone number) as to each problem and indicate whether this physician has
prescribed drugs to you for your symptoms. (List other physicians and contact information on a separate sheet of paper as needed)

Doctor No. 1:__________________________________________________________________________________

Address: ________________________________________________________________________________________________________

City: _______________________ State: _____________ Zip: ____________________

Telephone Number: (______)______-_________

Drug(s) prescribed? Yes / No Name of Drug(s): __________________________________________

Doctor No. 2:__________________________________________________________________________________

Address: ________________________________________________________________________________________________________

City: _______________________ State: _____________ Zip: ____________________

Telephone Number: (______)______-_________

Drug(s) prescribed? Yes / No Name of Drug(s): __________________________________________

Doctor No. 3:__________________________________________________________________________________

Address: ________________________________________________________________________________________________________

City: _______________________ State: _____________ Zip: ____________________

Telephone Number: (______)______-_________

Drug(s) prescribed? Yes / No Name of Drug(s): __________________________________________

Doctor No. 4:__________________________________________________________________________________

Address: ________________________________________________________________________________________________________

City: _______________________ State: _____________ Zip: ____________________

Telephone Number: (______)______-_________

Drug(s) prescribed? Yes / No Name of Drug(s): __________________________________________

Have you been diagnosed with "Adjuvant Breast Disease"? Yes / No

If yes, by whom, when and describe what the nature of the problem was: ________________________________________

Have your implants ever ruptured? Yes / No

Have your implants ever capsulated? Yes / No

Have you had regular mammographies? Yes / No

Date of last exam ____________/____________/_____________

Have any of your mammographies been abnormal? Yes / No

If so, when?

Do you have a copy? Yes / No If so, please attach a copy (See Below)

2. Have you ever received any monies or settlements in any way related to your implants from:

Any Records from Hospital(s) where each set of implants was either implanted and/or removed (Exhibit "1").

Records from any Implant Doctor’s Office (Attach as Exhibit "3")

Any Medical Bills (Attach at Exhibit "4")

Any Records from your current Doctor’s Offices, including:

Treating Doctors (annual check-up, mammographies, etc.) (Exhibit ("5")

Dermatologists (Exhibit "6")

Plastic Surgeon’s Records (Exhibit "7")

Medical Bills from all of these (Exhibit "8")

Records from any past Doctor’s Offices, including:

Any illnesses that were treated (Exhibit "9")

Any unusual illnesses of children born after implants (Exhibit "10")

The manufacturer’s labels from your implants (Exhibit "11") (If you do not have these, have you ever had them? _______ If so, where are they now? ______________________________)

Proof of claim (Exhibit "13")

The undersigned certifies that all of the information given is true and correct to the best of the his/her knowledge. I/We understand that all Pearson & Pearson, P.C. ("P&P") is agreeing to at this time is to look at our case and that by completing, filling out, and faxing this form to Pearson & Pearson, P.C. no Attorney-Client relationship is yet formed.

Until P & P agrees to accept this case, and a written contract is executed by both the undersigned and P & P, P & P can and will take no action to protect our rights. We also request P & P, or any other law firm working in conjunction with P & P, to review this material and to call/contact us to discuss this matter further.

Date: _____________________ Date: _____________________

_______________________________________ _______________________________________