Name

Phone Number

Email Address

Which Implant Do You Have?
Please Check the Box Below

DePuy ASR™ XL

DePuy Pinnacle

Smith & Nephew Birmingham

Zimmer Durom®

Biomet® Metal-on-Metal Hip

Other / Not sure

What Problems are
you Experiencing?

Pain

Rashes/Inflammation

Popping/Clicking Noises

Loosening

Misalignment

Fracture

Dislocation