Boston Scientific Class Action Questionnaire

I would like to be included as a group member of the Boston Scientific Class Action (“BSCA”) commenced by AJB Stevens Lawyers (“AJBSL”).

I instruct AJBSL to act on my behalf in respect of my compensation claim as a group member in the BSCA.

I understand that I will be provided with a cost agreement by AJBSL which I will be asked to sign once I have read and agreed with the terms and conditions of the agreement. This costs agreement will be provided to all group members.

I understand that if the BSCA is not successful, as a group member, I will not be charged nor will I be liable to pay any legal costs to AJBSL or any other party.

If I have not as yet provided a BSCA Questionnaire to AJBSL, then I understand that by submitting this form, a questionnaire will be sent to me which I will be asked to complete and return to AJBSL.

This questionnaire together with the medical records which AJBSL will obtain on my behalf will ultimately determine my entitlement to become a group member in the BSCA.