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First Name*

Last Name*

Phone*

e.g. 555-555-5555

Email*

Have you undergone any of the following medical procedures since 2018?*

When did you undergo the listed procedure (If you don't know the exact date, please give your best approximation)*

In which state did you undergo the procedure?*

Did you experience an infection, condition, or medical problem within 90 days of the procedure?*

Yes

No

Which of the following conditions did you experience within 90 days of the procedure?*

Infection

Sepsis

Superbug

Tuberculosis

HIV

Other

Were you hospitalized as a result of the condition you suffered? *

Yes

No

When would be a good time to call you?

Central Time

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I Consent