Uterine Artery Embolization Report

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:

Name*
First Last
Email*
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Doctor(s) Name(s):
Date(s) of Procedure(s):
* 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:
Where should this report be sent?*
- Report to the FDA and the HERS Foundation
- Only report to HERS Foundation
Privacy Policy: The adverse effects reported by women build our database of the consequences of this surgery. All information is strictly confidential unless you specifically ask us to provide your information to FDA.

* 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.

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