TO BE COMPLETED BY ULTRASOUND TECHNICIAN

All suspected ruptures require images & video to send for confirmation by the Ultrasound Consultant

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1. STUDY SITE NUMBER: (enter the assigned number for your site)

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2. Subject Initials (Two Characters)

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3. Confidential Subject ID (3 Numbers)

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4. Scan Completed by (Last Name)

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Note Diagram Before Continuing

Note Diagram Before Continuing

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5. Was a radial scan of all 4 quadrants performed for each breast implant?

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6. Was an implant rupture detected?

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