• Name
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• Was the infection after 2015?*
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• Did the infection occur within 1 year after the procedure?*
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• Were you hospitalized and given IV antibiotics?*
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• Did you experience any of the following infections?*
  Select OneBacterial infection resulting in hospitalizationSepsis or bacteremiaPneumonia or severe pulmonary infectionTuberculosis diagnosed within 1 year after scopingHIV diagnosed within 1 year after scopingDocumented superbug or antibiotic-resistant organismOtherMinor or self-limited infectionRoutine post-procedure discomfort onlySymptoms resolved without escalation
• Did you have a scope or endoscopic procedure from the list below?*
  Select OneColonoscopyEGD - Gastroscopy - Upper EndoscopyERCP - Endoscopic Retrograde CholangiopancreatographyPOEM - Peroral Endoscopic MyotomyCystoscopyUreteroscopyNephroscopy - kidney scope proceduresBPH treatment via scope-based placement - including iTindBronchoscopyEBUS - Endobronchial UltrasoundHysteroscopyLaparoscopyColposcopyNasal endoscopy/sinus endoscopyLaryngoscopy and other scope-based ENT procedures
• Are you able to obtain your medical records?*
  Select OneYesNo
• Do you or a loved one currently have a lawyer representing your claim?*
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• Name*
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