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First Name

Last Name

Email Address

Phone Number

Cell Phone Number

Street Address

City

State Choose State ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING

Zip Code

Date of birth of injured person (mm/dd/yyyy):

Date Defibrillator or Pacemaker was Implanted

Name of Defibrillator or Pacemaker that was Implanted

Date Lead was Implanted (If different) (mm/dd/yyyy)

Have you ever experienced multiple shocks?

Yes No

If yes, please describe shocks and any associated problems

Has your pacemaker or defibrillator ever failed to work?

Yes No

If yes, please describe shocks and any associated problems

Has your pacemaker/defibrillator or lead been REPLACED?

Please further describe any other complications

Other information

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