Canadian Vitek Tmj Implant Settlement
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EXHIBIT “A”
REGISTRATION / OPT IN FORM
CANADIAN VITEK TMJ IMPLANT SETTLEMENT
The following is Identification of the Class Member submitting a Claim.Mr./ Mrs./ Ms./ etc... First Name Middle Name/ Initial / Last Name / Any prior Last Name(s)
Current Address / City
Province / Postal Code
( )
Telephone Number / Date of Birth / Date of Death
(if deceased) / Social Insurance Number
IF YOU CHANGE YOUR ADDRESS, PLEASE INFORM THE CLAIMS ADMINISTRATOR IN WRITING.
1.Do you have a lawyer representing you in connection with a temporomandibular joint implant claim?
No.
Yes. If yes, please provide the lawyer’s name, address and telephone number:
______
2.In the event of a written appeal, in which Court do you wish your appeal to be heard?:
Ontario Quebec British Columbia
Note: If you reside outside of British Columbia, you will be deemed to opt into the British Columbia Class if you indicate in this Section, your desire to have your appeal dealt with before the court in British Columbia. If you are a Quebec or Ontario resident and have opted into the British Columbia Class you will be deemed to have opted out of the Quebec or Ontario Class.
3.Did you previously register in the Backstrom v. Methodist Hospital Settlement?
No.
Yes. If yes, please attach a copy of your Compensation Claim Form.
(Previous medical records do not need to be re-submitted.)
4.Please provide a list of any Vitek Proplast surgeries you have undergone (attach additional information if necessary):
Surgery Date: Description of Surgery:
______
______
5.Have you ever had any of the following documented?
Bone Resorption
No. Yes. Attach medical records, x-rays, tomograms and/ or MRI’s documenting resorption of the glenoid fossa that were not previously submitted to the Backstrom v. Methodist Hospital Settlement.
Granuloma or Foreign Body
No. Yes. Attach medical records, including but not limited to pathology reports, x-rays, tomograms and/ or MRI documenting Granuloma and/ or Foreign Body reaction that were not previously submitted to the Backstrom v. Methodist Hospital Settlement.
6.Identification of person signing this Claim (check one only please):
I am the above identified Vitek implant recipient. I am signing this Form to make a Claim for benefits under the Canadian Vitek TMJ Implant Settlement. With this Form, I have included Product Identification as required in the Settlement.
I am the legal guardian, custodian, executor, administrator or court-appointed representative of the above identified person (or his/ her estate). I am signing this Form to make a Claim on her/his (or his/ her estate’s) behalf for benefits under the Canadian Vitek TMJ Implant Settlement. With this Form, I have included Product Identification as required in the Settlement. [If not previously provided, attach a copy of court order or other official document appointing you as representative and state you name, title, mailing address and telephone number (rather than the implant recipient’s) in the blocks on the first page of this Form.]
I declare under penalty of perjury that the information on this Form is true, correct and complete to the best of my knowledge, information and belief.
______
Date Signed Signature (Implant Recipient or Personal Representative)
NOTE: 1.Be certain to attach all other necessary documents as well as documents that were not previously submitted to the Backstrom v. Methodist Hospital Settlement, including:
(a)a copy of our Birth Certificate, or other proof of date of birth;
(b)all medical records necessary to establish your entitlement to compensation.
2.To preserve eligibility for benefits under the Settlement, this Form MUST be completed, signed and mailed to the Claims Administrator postmarked no later than ,1999. If postmarked later than that date, the claim will not be considered.
THE INFORMATION PROVIDED IN THIS FORM WILL REMAIN CONFIDENTIAL
AS PROVIDED IN THE CANADIAN VITEK TMJ IMPLANT SETTLEMENT.
Please mail this Form to the CLAIMS ADMINISTRATOR at:
XXX Street
London, Ontario, Canada
XXX XXX