Form B-Application Form DePuy ASR Alternative Dispute Resolution Process – FORM B Claimant Details Name Address Date of Birth Occupation ASR-IRL Patient Number Claimant’s Solicitor Name Claimant’s Solicitor’s Address Claimant’s Solicitor’s Reference Hip implanted Left Right (please tick the appropriate box) Bilateral The Claimant an expedited Evaluation of their Claim If yes, please provide a reason Index Surgery Details Date of Surgery Type of Surgery ASR Hip Resurfacing ASR XL Total Hip Replacement (please tick the appropriate box) Other Hospital Surgeon Revision Surgery Details Date of Revision Surgery
Form B-Application Form DePuy ASR – Alternative Dispute Resolution Process FORM B Claimant Details Name Address Date of Birth Occupation ASR-IRL Patient Number Claimant’s Solicitor Name Claimant’s Solicitor’s Address Claimant’s Solicitor’s Reference Hip implanted (please tick the appropriate box) Left Right Bilateral The Claimant an expedited Evaluation of their Claim If yes, please provide a reason Index Surgery Details Date of Surgery Type of Surgery (please tick the appropriate box) ASR Hip Resurfacing ASR XL Total Hip Replacement Other Hospital Surgeon Revision Surgery Details Date of Revision Surgery