Endometrial Ablation Report – HERS Foundation

If you would like to report the adverse effects you experienced after Endometrial Ablation 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 method of endometrial ablation, ie rollerball, balloon, thermal, microwave, cryo (freezing):
If known, the manufacturer of the device used in the procedure:
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.

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