intake test forms

 
Do you have an Essure birth control implant?



Are you experiencing problems related to your Essure implant?



Are you already represented by an attorney?











I understand that by submitting this form I am not entering into an attorney-client relationship.

*indicates required field

Do you have an Essure birth control implant?



Are you experiencing problems related to your Essure implant?



Are you already represented by an attorney?











I understand that by submitting this form I am not entering into an attorney-client relationship.

*indicates required field