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:

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 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:

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

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.

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