Lifted Logic Web Design in Kansas City
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Main Menu
Contact Us
800.701.3672
Do I Have a Case?
Contact Us
800.701.3672
Do I Have a Case?
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8101 College Blvd, Suite 260
Overland Park, KS 66210
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Are you completing this on behalf of yourself or someone else?
Myself
Someone Else
Were you injured by:
Defective Device
Dangerous Drug
Personal Injury
Employment Issue
Was your loved one injured by:
Defective Device
Dangerous Drug
Personal Injury
Employment Issue
Was the defective device surgically implanted?
*
Yes
No
I Don't Know
What was the name of the device ?
*
When did you start using the device?
*
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
Before
When did you begin to have issues after using the device?
*
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
Before
When did your loved one begin using the device
*
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
Before
When did your loved one begin to experience issues with the device
*
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
Before
Describe the issues that were experienced
*
Where was the device implanted?
Head
Neck
Shoulder
Chest
Arm
Abdomen
Groin
Upper Leg
Knee
Lower Leg
Ankle
Foot
Back
When was the device implanted?
Month
*
Please Select:
January
February
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
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2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
I don't know
When did your loved one begin having problems with their device?
Month
*
Please Select:
January
February
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
I don't know
When did you begin having problems with your device?
Month
*
Please Select:
January
Februrary
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
I don't know
Describe the issues that were experienced:
*
Has the device been surgically removed or altered?
Yes, more than once
Yes, once
No
When was the device surgically removed or altered?
Month
*
Please Select:
January
February
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2022
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
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2008
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2006
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2004
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1998
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1995
1994
1993
1992
1991
1990
I don't know
When was the first time the device was surgically removed?
Month
*
Please Select:
January
February
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
I don't know
When was the first time your loved one's device was surgically removed?
Month
*
Please Select:
January
February
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
I don't know
When was the second time the device was surgically removed?
Month
*
Please Select:
January
February
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
I don't know
Was this the last surgery?
*
Yes
No
When was the second time your loved one's device was surgically removed?
Month
*
Please Select:
January
February
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
I don't know
Was this the last surgery?
*
Yes
No
When was the third time the device was surgically removed?
Month
*
Please Select:
January
February
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
I don't know
Was this the last surgery?
*
Yes
No
When was the third time your loved one's device was surgically removed?
Month
*
Please Select:
January
February
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
I don't know
Was this the last surgery?
*
Yes
No
When was the fourth time the device was surgically removed?
Month
*
Please Select:
January
February
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
I don't know
Was this the last surgery?
*
Yes
No
When was the fourth time your loved one's device was surgically removed?
Month
*
Please Select:
January
February
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
I don't know
Was this the last surgery?
*
Yes
No
When was the fifth time the device was surgically removed?
Month
*
Please Select:
January
February
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
I don't know
Was this the last surgery?
*
Yes
No
When was the fifth time your loved one's device was surgically removed?
Month
*
Please Select:
January
February
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
I don't know
Was this the last surgery?
*
Yes
No
When was the sixth time the device was surgically removed?
Month
*
Please Select:
January
February
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
I don't know
Was this the last surgery?
*
Yes
No
When was the sixth time your loved one's device was surgically removed?
Month
*
Please Select:
January
February
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
I don't know
Was this the last surgery?
*
Yes
No
Have you had seven or more surgeries?
Yes
No
Has your loved one had seven or more surgeries?
Yes
No
What drug did you take?
*
What shape was the drug?
Round
Oblong
Oval
Square
Rectangle
Diamond
3 Sided
Other
When did you start taking it?
Month
*
Please Select:
January
February
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
I don't know
Are you still taking it?
Yes
No
When did you stop taking it?
Month
*
Please Select:
January
February
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
I don't know
How were you injured?
Cancer
Other
What type of Cancer were you diagnosed with?
*
What date were you diagnosed?
Month
*
Please Select:
January
February
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
I don't know
Describe your injuries.
*
When did this occur?
Month
*
Please Select:
January
February
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
I don't know
Was your medication purchased over the counter or prescribed?
Over The Counter
Prescription
Both
Did you use a Brand Name or Generic?
Brand Name
Generic
What happened?
Traffic Accident
Slip & Fall
Medical Negligence
Nursing Home
Employment
Other
Describe the accident?
*
Describe the accident?
*
When did this happen?
Month
*
Please Select:
January
February
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
I don't know
When did this happen?
Month
*
Please Select:
January
February
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
I don't know
Is there a Police Report?
Yes
No
Is there a Police Report?
Yes
No
Was your loved one at fault?
Yes
No
Were you at fault?
Yes
No
Describe what happened?
*
Describe what happened?
*
Describe what happened?
*
Describe what happened?
*
Describe what happened?
*
Describe what happened?
*
Describe what happened?
*
Describe what happened?
*
When did this happen?
Month
*
Please Select:
January
February
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
I don't know
When did this happen?
Month
*
Please Select:
January
February
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
I don't know
When did this happen?
Month
*
Please Select:
January
February
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
I don't know
When did this happen?
Month
*
Please Select:
January
February
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
I don't know
When did this happen?
Month
*
Please Select:
January
February
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
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1993
1992
1991
1990
I don't know
When did this happen?
Month
*
Please Select:
January
February
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
I don't know
When did this happen?
Month
*
Please Select:
January
February
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
I don't know
When did this happen?
Month
*
Please Select:
January
February
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
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1995
1994
1993
1992
1991
1990
I don't know
Where did your loved one fall?
*
Where did you fall?
*
Was your loved one hospitalized?
Yes
No
Were you hospitalized?
Yes
No
How long?
Overnight
1 day
2-3 days
4 or more days
How long?
Overnight
1 day
2-3 days
4 or more days
Any surgery?
Yes
No
Any surgery?
Yes
No
Any surgery?
Yes
No
Any surgery?
Yes
No
Describe:
*
Describe:
*
Describe:
*
Describe:
*
Is your loved one still treating?
Yes
No
Is your loved one still treating?
Yes
No
Are you still treating?
Yes
No
Are you still treating?
Yes
No
Has the hospital contacted you?
Yes
No
Has the hospital contacted you?
Yes
No
Is your loved one still receiving medical treatment for their injury?
Yes
No
Are you still treating?
Yes
No
Did you report this to the facility?
Yes
No
Did you report this to the facility?
Yes
No
Does the facility take state Medicaid?
*
Does the facility take state Medicaid?
*
Were you terminated?
Yes
No
Was your loved one terminated?
Yes
No
Describe what happened?
Describe what happened?
*
When did this happen?
Month
*
Please Select:
January
February
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
I don't know
When did this happen?
Month
*
Please Select:
January
February
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
I don't know
Did your employer break any laws?
Yes
No
Did your loved one's employer break any laws?
Yes
No
What drug did your loved one take?
*
When did your loved one start taking it?
Month
*
Please Select:
January
February
March
April
May
June
July
August
September
October
November
December
I don't know
Year
*
Please Select:
2023
2022
2021
2020
2019
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Is your loved one still taking it?
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When did your loved one stop taking it?
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I don't know
How was your loved one injured?
Cancer
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What type of Cancer was your loved one diagnosed with?
*
When was your loved one diagnosed?
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How was your loved one injured?
*
When did this occur?
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I don't know
Was your loved one's medication purchased over the counter or prescribed?
Over The Counter
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Did your loved one use a Brand Name or Generic?
Brand Name
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In what state did the injury occur?
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