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Class Action Form

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Personal Details

Salutation

Name

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Date of Birth

DD slash MM slash YYYY

Phone

Claimant Details

A claimant is the person who is claiming loss. If you are registering on behalf of someone else, please fill in the details of the person you are registering on behalf of below.

Is this registration made for yourself, or on behalf of someone else?

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Date of Birth

DD slash MM slash YYYY

What is their relationship to you?

Do you have authority to complete this form on their behalf?

Implant/s

Mesh Implants (for prolapse of bladder, vagina, rectum or uterus)

Type of Mesh Implant

Please specify the type, brand and/or manufacturer if known

Date of implant surgery

DD slash MM slash YYYY

Surgeon

First Last

Hospital

GP at time of implant

Name of GP: Name of practice:

Were you treated as a public or private patient?

If you were treated as a private patient, who was your private health insurer?

Previous Claim

Have you sued or sought compensation or damages from a doctor or hospital for having one of the Implants inserted?

If Yes, were you successful and received a sum in compensation or damages?

and received a sum of ………………………

Medical Background

State the number of vaginal births you have had?

State the number of caesarean section births you have had?

In chronological order (earliest to latest), list any and all surgeries, procedures, or hospitalisations you had in the 10 year period BEFORE implantation of the pelvic mesh product(s). For each procedure use the following format – Approximate date – Description of surgery hospitalisation – Doctor or healthcare provider involved (including address).

In chronological order (earliest to latest), list any and all surgeries, procedures, or hospitalisations you had in the 10 year period AFTER the implantation of the pelvic mesh product(s). For each procedure use the following format – Approximate date – Description of surgery hospitalisation – Doctor or healthcare provider involved (including address).

To the best of your knowledge, have you suffered from any of the following:

Medical Condition

Adhesions

Sought treatment for Adhesions

Indicate whether Adhesions occurred pre-implant, post-implant or both

Adhesions Pre and Post explanation (explain, if necessary)

Bleeding or Clotting Disorders

Sought treatment for Bleeding or clotting disorders?

Indicate whether Bleeding or Clotting Disorders occurred pre-implant, post-implant or both

Bleeding or Clotting Pre and Post explanation (explain, if necessary)

Bowel Obstruction

Sought treatment for Bowel Obstruction?

Indicate whether condition occurred pre-implant, post-implant or both

Bowel Obstruction Pre and Post explanation (explain, if necessary)

Bowel Perforation

Sought treatment for Bowel Perforation?

Indicate whether condition occurred pre-implant, post-implant or both

Bowel Perforation Pre and Post explanation (explain, if necessary)

Cancer

Sought treatment for cancer?

Indicate whether condition occurred pre-implant, post-implant or both

Please specify type Of Cancer:

Cancer Pre and Post explanation (explain, if necessary)

Chronic constipation

Sought treatment for Chronic constipation?

Indicate whether Chronic constipationI occurred pre-implant, post-implant or both

Chronic constipation Pre and Post explanation

Collagen Disorder / Deficiency

Sought treatment for Collagen Disorder / Deficiency?

Indicate whether Collagen Disorder / Deficiency occurred pre-implant, post-implant or both (explain, if necessary)

Collagen Disorder / Deficiency Pre and Post explanation

Connective Tissue Disorder

Sought treatment for Connective Tissue Disorder?

Indicate whether Connective Tissue Disorder occurred pre-implant, post-implant or both (explain, if necessary)

Please specify Connective Tissue Disorder

Connective Tissue Disorder Pre and Post explanation

Crohn’s Disease, Irritable Bowel Syndrome, Ulcerative Colitis, or Chronic Diarrhoea

Sought treatment for Crohn’s Disease, Irritable Bowel Syndrome, Ulcerative Colitis, or Chronic Diarrhoea?

Indicate whether Crohn’s Disease, Irritable Bowel Syndrome, Ulcerative Colitis, or Chronic Diarrhoea occurred pre-implant, post-implant or both (explain, if necessary)

Please specify which condition and treatment prescribed

Crohn’s Disease, Irritable Bowel Syndrome, Ulcerative Colitis, or Chronic Diarrhoea Pre and Post explanation

Cystocele

Sought treatment for Cystocele?

Indicate whether Cystocele occurred pre-implant, post-implant or both (explain, if necessary)

Cystocele Pre and Post explanation

Diabetes

Sought treatment for Diabetes?

Indicate whether Diabetes occurred pre-implant, post-implant or both (explain, if necessary)

Diabetes Pre and Post explanation

Diverticulitis

Sought treatment for Diverticulitis?

Indicate whether Diverticulitis occurred pre-implant, post-implant or both (explain, if necessary)

Diverticulitis Pre and Post explanation

Dyspareunia

Sought treatment for Dyspareunia?

Indicate whether Dyspareunia occurred pre-implant, post-implant or both (explain, if necessary)

Dyspareunia Pre and Post explanation

Enterocele

Sought treatment for Enterocele?

Indicate whether Enterocele occurred pre-implant, post-implant or both (explain, if necessary)

Enterocele Pre and Post explanation

Fistulas

Sought treatment for Fistulas?

Indicate whether Fistulas occurred pre-implant, post-implant or both (explain, if necessary)

Fistulas Pre and Post explanation

Hernias

Sought treatment for Hernias

Indicate whether Hernias occurred pre-implant, post-implant or both (explain, if necessary)

Hernias Pre and Post explanation

Hypertension or High Blood Pressure

Sought treatment for Hypertension or High Blood Pressure?

Indicate whether Hypertension or High Blood Pressure occurred pre-implant, post-implant or both (explain, if necessary)

Hypertension or High Blood Pressure Pre and Post explanation

Hypotension or Low Blood Pressure

Sought treatment for Hypotension or Low Blood Pressure?

Indicate whether Hypotension or Low Blood Pressure occurred pre-implant, post-implant or both (explain, if necessary)

Hypotension or Low Blood Pressure Pre and Post explanation

Immune System Disease or Dysfunction including HIV/AIDS

Sought treatment for Immune System Disease or Dysfunction including HIV/AIDS?

Indicate whether Immune System Disease or Dysfunction including HIV/AIDS occurred pre-implant, post-implant or both (explain, if necessary)

Immune System Disease or Dysfunction including HIV/AIDS Pre and Post explanation

Please specify condition

Malnutrition

Sought treatment for Malnutrition?

Indicate whether Malnutrition occurred pre-implant, post-implant or both (explain, if necessary)

Malnutrition Pre and Post explanation

Muscle or Muscle-wasting disorder

Sought treatment for Muscle or Muscle-wasting disorder?

Indicate whether Muscle or Muscle-wasting disorder occurred pre-implant, post-implant or both (explain, if necessary)

Muscle or Muscle-wasting disorder Pre and Post explanation

Please specify condition

Neuromuscular Disease or Disorder

Sought treatment for Neuromuscular Disease or Disorder?

Indicate whether Neuromuscular Disease or Disorder occurred pre-implant, post-implant or both (explain, if necessary)

Neuromuscular Disease or Disorder Pre and Post explanation

Please specify condition

Obesity

Sought treatment for Obesity?

Indicate whether Obesity occurred pre-implant, post-implant or both (explain, if necessary)

Obesity Pre and Post explanation

Pelvic Trauma

Sought treatment for Pelvic Trauma?

Indicate whether Pelvic Trauma occurred pre-implant, post-implant or both (explain, if necessary)

Pelvic Trauma Pre and Post explanation

Please describe trauma

Pelvic Tumors or Fibroids

Sought treatment for Pelvic Tumors or Fibroids?

Indicate whether Pelvic Tumors or Fibroids occurred pre-implant, post-implant or both (explain, if necessary)

Pelvic Tumors or Fibroids Pre and Post explanation

Peritonitis/Sepsis

Sought treatment for Peritonitis/Sepsis?

Indicate whether Peritonitis/Sepsis occurred pre-implant, post-implant or both (explain, if necessary)

Peritonitis/Sepsis Pre and Post explanation

Rectocele

Sought treatment for Rectocele?

Indicate whether Rectocele occurred pre-implant, post-implant or both (explain, if necessary)

Rectocele Pre and Post explanation

Recurrent or Chronic Vaginal or Bladder Infections

Sought treatment for Recurrent or Chronic Vaginal or Bladder Infections?

Indicate whether Recurrent or Chronic Vaginal or Bladder Infections occurred pre-implant, post-implant or both (explain, if necessary)

Recurrent or Chronic Vaginal or Bladder Infections Pre and Post explanation

Please specify location and nature of infections:

Recurrent Vaginal pain

Sought treatment for Recurrent Vaginal pain?

Indicate whether Recurrent Vaginal pain occurred pre-implant, post-implant or both (explain, if necessary)

Please describe the nature of pain experienced:

Urinary Incontinence

Sought treatment for Urinary Incontinence?

Indicate whether Urinary Incontinence occurred pre-implant, post-implant or both (explain, if necessary)

Urinary Incontinence Pre and Post explanation

Urinary Retention

Sought treatment for Urinary Retention?

Indicate whether Urinary Retention occurred pre-implant, post-implant or both (explain, if necessary)

Urinary Retention Pre and Post explanation

Uterine Prolapse

Sought treatment for Uterine Prolapse?

Indicate whether Uterine Prolapse occurred pre-implant, post-implant or both (explain, if necessary)

Uterine Prolapse Pre and Post explanation

Vaginal Vault Prolapse

Sought treatment for Vaginal Vault Prolapse?

Indicate whether Vaginal Vault Prolapse occurred pre-implant, post-implant or both (explain, if necessary)

Vaginal Vault Prolapse Pre and Post explanation

Wound Healing Problems

Sought treatment for Wound Healing Problems?

Indicate whether Wound Healing Problems occurred pre-implant, post-implant or both (explain, if necessary)

Wound Healing Problems Pre and Post explanation

Please explain the Wound Healing Problems

Any other disease of the gut, intestines, or bowels

Sought treatment for Any other disease of the gut, intestines, or bowels?

Indicate whether Any other disease of the gut, intestines, or bowels occurred pre-implant, post-implant or both (explain, if necessary)

Any other disease of the gut, intestines, or bowels Pre and Post explanation

Please specify Any other disease of the gut, intestines, or bowels (s):

Have you experienced menopause?

At what age did Menopause begin?

Have you undergone vaginal estrogen therapy, hormone therapy, or systemic estrogen replacement therapy (ERT)?

Please provide the type of therapy you received, date(s) of the therapy, and the name and address of the healthcare provider providing the therapy.

Do you now or have you ever smoked tobacco products?

How long have / did you smoke in years?

List each prescription medication you have taken for more than 3 months at a time, within the last 5 years prior to implant to present, giving the reason you took the medication, and the approximate dates of use

SURGICAL TREATMENT

Have you required further surgery to treat complications following the initial surgery to implant the the IVS or TFS Implants?

How many further operations have you undergone?

Is any further surgery planned by your doctor? If so when?

When is the surgery planned?

DD slash MM slash YYYY

Did the further surgery solve/improve the complication?

COMPLICATIONS

Have you experienced any of the following after your IVS or TFS Surgery?

Erosion, extrusion, protrusion

Do you still suffer from the Erosion, extrusion, or protrusion

Did you require surgery to treat erosion, extrusion or protrusion?

Was all the mesh removed?

Who performed the removal surgery?

When is the surgery?

DD slash MM slash YYYY

Does any medical treater, physical or anybody else on your behalf have possession of any portion of the mesh that was previously implanted in you and removed?

Please state the name and address of the person or entity having possession of same.

Pain

If so, where? (can be multiple locations) (please tick)

Please specify

Do you still suffer from the condition? (please tick if ‘yes’)

If so, where? (can be multiple locations) (please tick)

Please specify

Painful intercourse

Do you still suffer from the Painful intercourse?

Unable to have sexual intercourse

Do you still suffer from the being Unable to have sexual intercourse?

Sexual intercourse associated with incontinence of urine, faeces or wind

Do you still suffer from the Sexual intercourse associated with incontinence of urine, faeces or wind?

Difficulties with bowel motions, including loss of control or constipation

Do you still suffer from Difficulties with bowel motions, including loss of control or constipation?

Offensive vaginal discharge

Do you still suffer from Offensive vaginal discharge

Infection

Do you still suffer from Infection

At what site was the Infection

At what site was do you still suffer from Infection

Please Specify The other site of infection

Please Specify the other site of that you still suffer frominfection

Damage to pelvic organs, nerves, ligaments, tissue etc. (e.g. bladder or ureter damage)

Do you still suffer from Damage to pelvic organs, nerves, ligaments, tissue etc. (e.g. bladder or ureter damage)

Recurrent prolapse

Do you still suffer from Recurrent prolapse

Incontinence of urine not present before the operation to insert an implant

Do you still suffer from Incontinence of urine not present before the operation to insert an implant

Recurrent incontinence of urine

Do you still suffer from Recurrent incontinence of urine

Aggravation of pre- existing incontinence of urine

Do you still suffer from Aggravation of pre- existing incontinence of urine(Required)

Psychiatric injury

Do you still suffer from Psychiatric injury

Stroke, heart attack or other brain injury(Required)

Do you still suffer from Stroke, heart attack or other brain injury

CURRENT LEVEL OF PAIN

If you experience pain as a complication of your IVS or TFS Implant, please rate your pain at its worst in the last week. Use the scale of 0 to 10, with 0 being no pain and 10 being the worst imaginable pain.

CURRENT SEVERITY OF URINARY, BOWEL, VAGINAL AND SEXUAL SYMPTOMS

If you were to spend the rest of your life with your symptoms just the way they are now, how would you feel about that? Use the scale of 0 to 10, with 0 being ‘content’, 5 being ‘indifferent’ and 10 being ‘terrible’.

ACTIVITIES OF DAILY LIVING

Some women find that bladder, bowel, or vaginal symptoms or pain affect their activities, relationships, and feelings. For each question, check the response that best describes how much your activities, relationships, or feelings have been affected by your bladder, bowel, or vaginal symptoms or conditions or pain over the last 3 months. How do symptoms or conditions in the following affect your:

Ability to do household chores (cooking, laundry, housecleaning)?

Ability to do physical activities such as walking, swimming, or other exercise?

Entertainment activities such as going to a concert or movie?

Ability to travel by car or bus for a distance greater than 30 minutes away from home?

Participating in social activities outside your home?

Emotional health (nervousness, depression, etc.)?

Feeling frustrated?

Do you have pain daily? If so how bad is the pain?

CARE AND ASSISTANCE

As a result of the injuries/restrictions you have suffered due to the insertion of your IVS or TFS Implant, have you required assistance with your household chores i.e. washing, cleaning, showering, preparation of meals, gardening by an external provider or a member of your family?

Care Provider?

When did you start requiring assistance (approx. month and year)?

DD slash MM slash YYYY

Up until now, on average how many hours of assistance per week have you required?

What tasks or activities have you required assistance with?

In the future, how many hours of assistance do you think you will require per week?

ONGOING TREATMENT AS A RESULT OF YOUR IVS OR TFS IMPLANT

Pain Medication

Are you currently taking any pain medication as a result of your IVS or TFS implant?

For how many years or months have you been taking pain medication?

What pain medication do you take and at what dosage?

Did you require pain medication prior to the insertion of your IVS or TFS implant?

What pain medication did you take and at what dosage?

Other Medications

Are you currently taking any medication to treat a psychological condition you have

What medication do you take and at what dosage?

For how many years or months have you been taking medication?

Did you require medication to treat a psychological condition prior to the insertion of your IVS or TFS implant?

If yes, what medication did you take and at what dosage?

Are you currently using any topical treatments such as oestrogen cream, steroids or antibiotics to treat the injuries you have suffered as a result of your IVS or TFS implant?

If yes, for how many years or months have you been using this topical treatment?

What topical treatment do you use?

Did you require this topical treatment prior to the insertion of your IVS or TFS implant?

What topical treatment did you use?

Other Treatment

Do you currently undertake any other type of treatment as a result of your IVS or TFS implant? (For example physiotherapy, chiropractic, psychological treatment, incontinence pads, etc.)

What type of treatment?

How frequently do you receive this treatment?

PAYMENT OF YOUR TREATMENT AND REHABILITATION  EXPENSES

In answering the following questions, please consider any expenses associated with treatment for the failure or revision of your IVS or TFS implant and rehabilitation including the costs of revision surgery, consultations with your surgeon or another doctor, medical investigations (such as, x-rays, MRIs or other scans), physiotherapy or hydrotherapy, medication, aids or equipment, housing or vehicle modifications or other costs.

Have any of your treatment expenses been reimbursed or paid directly by a private health insurer?

Medicare or Department of Veterans Affairs

Have any of your treatment expenses been reimbursed or paid directly by Medicare or the Department of Veterans Affairs?

Out of pocket expenses

Are you out of pocket in relation to any treatment and rehabilitation expenses? In other words, have you paid any expenses that have not been covered by a private health insurer, Medicare or the Department of Veterans Affairs?

Please estimate the approximate amount. In answering this question, we do not need you to add up all of your invoices and receipts. Please simply give your best estimate of the total amount.

EMPLOYMENT STATUS

Were you doing paid work at the time of your IVS or TFS surgery?

If so, were you:

What was your average net weekly income (as reported in your tax return). This does not need to be an exact figure – an approximate amount is satisfactory.

Did you return to your usual work after your IVS or TFS Surgery?

Beyond the recovery time advised by your doctor prior to the IVS or TFS Implant surgery, have you required time off work?

Approximately how much time did you take off work? In Months

If you have not returned to work following your surgery, or if you have had to reduce the hours that you work due to your IVS or TFS Implant, what is your current annual income?

If you were you not doing paid work at the time of your IVS or TFS surgery, had you intended to commence or return to work at any time in the future?

When did you intend on commencing or returning to work after the IVS or TFS surgery?

What type of work had you intended to commence or return to and how much were you expecting to earn, on average, net per week from that work?

Please give brief details of any other important information regarding the impact of the IVS or TFS Implant(s) on your enjoyment of life, your income, your capacity to work and your capacity to care for yourself and others

CENTRELINK BENEFITS

Do you currently receive Centrelink benefits?

What type of benefit?

For how long have you received Centrelink benefits? In Months

Completed forms must be returned so that they are received by AJB Stevens Lawyers before 4.30pm on 29 October 2021. If you have any questions please telephone AJB Stevens Lawyers on 02 8268 0600, or email us at TFSandIVS@ajbstevens.com.au

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Class Action Form

Claimant Details

Implant/s

Type of Mesh Implant

Previous Claim

Medical Background

Medical Condition

SURGICAL TREATMENT

COMPLICATIONS

CURRENT LEVEL OF PAIN

CURRENT SEVERITY OF URINARY, BOWEL, VAGINAL AND SEXUAL SYMPTOMS

ACTIVITIES OF DAILY LIVING

CARE AND ASSISTANCE

ONGOING TREATMENT AS A RESULT OF YOUR IVS OR TFS IMPLANT

Pain Medication

Other Medications

Other Treatment

PAYMENT OF YOUR TREATMENT AND REHABILITATION  EXPENSES

EMPLOYMENT STATUS

Expertise

Office

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Expertise

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Office

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Family Law

Will & Estate Disputes

Abuse Law

Compensation

Class Actions

Call us Now

Class Action Form

Claimant Details

Implant/s

Type of Mesh Implant

Previous Claim

Medical Background

Medical Condition

SURGICAL TREATMENT

COMPLICATIONS

CURRENT LEVEL OF PAIN

CURRENT SEVERITY OF URINARY, BOWEL, VAGINAL AND SEXUAL SYMPTOMS

ACTIVITIES OF DAILY LIVING

CARE AND ASSISTANCE

ONGOING TREATMENT AS A RESULT OF YOUR IVS OR TFS IMPLANT

Pain Medication

Other Medications

Other Treatment

PAYMENT OF YOUR TREATMENT AND REHABILITATION EXPENSES

EMPLOYMENT STATUS

Expertise

Office

Class Action

Expertise

Quick Links

Office

Class Action

Call us Now

PAYMENT OF YOUR TREATMENT AND REHABILITATION  EXPENSES