National Injury Help | Essure Claims Evaluation - ZAP

*Did you or a loved one have the Essure birth control device implanted for permanent birth control?
- Yes
- No

*What Date did you have the Essure birth control device implanted?
MM slash DD slash YYYY

Untitled*
* Based on your responses, you may qualify for compensation! Please provide additional comments to help evaluate your case.

Name*
First Last
Email*
Phone*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date
MM slash DD slash YYYY
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