Bowling-Pfizer Settlement Funds

525 Vine Street, Suite 2300
Cincinnati, Ohio 45202-3124
(800) 977-0779
(513) 421-7696 (fax)
bowlingpfizer@fuse.net


Class Action Registration
Full Name:
Gender:
Date of Birth:	(mm/dd/yyyy)
Street Address:
City:
State:
Zip/Postal Code:
Country:
Telephone Number:
Email Address:
BSCC Heart Valve Serial Number(s):
Implant Position of BSCC Heart Valve(s):
Implantation Date of BSCC Heart Valve(s):	(mm/dd/yyyy)
Has the BSCC valve been replaced?:
If “yes”, when was it replaced?