UAE | Report Your Complications

If you would like to report the adverse effects you experienced after Uterine Artery Embolization to the HERS Foundation and FDA please fill out the following form:

Confidential Report Form \| You may read our Privacy Policy Here
First Name:
Last Name:
Email:
Phone #:
Address:
Address2:
City:
State:
Zip:
Doctor(s) name(s)
Date(s) of procedure(s) - MM/DD/YY
* If known, the material used to occlude the uterine arteries, i.e., PVA, gelfoam pledgets, coils, etc.
* If known, the manufacturer of the materials used to occlude the uterine arteries:
Please describe the adverse effects you experienced:
Please select only ONE of the Reporting Options below:
Click this button to send report to Both:	Report to the FDA & the HERS Foundation
Click on this button if you do not want to report to FDA:	Only report to HERS Foundation

* If you would like to know the name and manufacturer of the product used to occlude your uterine arteries, (i.e. Polyvinyl alcohol particles manufactured by Cook) go to the medical records department in the hospital in which the surgery was performed and ask for an itemized copy of your bill.

Privacy Policy:
The adverse effects reported by women build our database of the consequences of this surgery. All information is strictly confidential unless you have specifically asked us to provide your information to FDA.

Confidential Report Form | You may read our Privacy Policy Here

First Name:

Last Name:

Email:

Phone #:

Address:

Address2:

City:

State:

Zip:

Doctor(s) name(s)

Date(s) of procedure(s) - MM/DD/YY

* If known, the material used to occlude the uterine arteries, i.e., PVA, gelfoam pledgets, coils, etc.

* If known, the manufacturer of the materials used to occlude the uterine arteries:

Please describe the adverse effects you experienced:

Please select only ONE of the Reporting Options below:

Click this button to send report to Both:

Report to the FDA & the HERS Foundation

Click on this button if you do not want to report to FDA:

Only report to HERS Foundation

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