SLF-pharma-tvm

First Name*

Last Name*

Phone Number*

Email*

City

State

Zip Code*

Did you or a loved one have transvaginal mesh implanted?*

Yes No Unsure

When did the original mesh surgery happen?

Was additional surgery necessary to repair or remove the mesh?*

Yes – the additional surgery already occurred Yes – the additional surgery is scheduled No – an additional surgery was not necessary Other (please add comments below)

Comments

In order to be most prepared to speak to you, please describe your situation and legal needs.

Yes

Yes, I understand and agree that submitting this form does not create an attorney-client relationship and is not confidential or privileged and may be shared. I understand and agree to the Privacy Policy & Terms of Use.

gClid

intake source

gasource

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gamedium

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gacampaign

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gaterm

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gacontent

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URL

matchtype

network

mkwid

clientid