Surgical Retained Instrument Compensation Claim Form
Submit your claim regarding a retained surgical instrument. Please complete all required fields to help us process your request efficiently.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hospital or Facility Name
*
Type of Retained Instrument
*
Please Select
Sponge
Clamp
Needle
Retractor
Other
Attending Surgeon Name
Brief Description of the Incident
*
Describe the Effects or Impact Experienced
*
Upload Supporting Documentation (e.g., reports, images)
Upload a File
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