THIS FORM IS TO BE COMPLETED BY THE SUBJECT IF THERE IS A SUSPECTED RUPTURE

This survey is designed to learn how you feel about possible silent rupture of your silicone gel breast implants after learning the results of the ultrasound scan. Questions refer only to your current silicone gel implants, not any implants you may have had previously. Check one answer for each question, unless otherwise indicated.

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1. As your ultrasound scan did not show an implant rupture, which of the statements below apply to you? (check all that apply)

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2. Going forward, would you get in-office ultrasound scans regularly to screen for silent rupture?

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3. If you were getting breast implants for the first time today, which of the 3 different implant types would you consider? (check all options that you would consider)

0 of 6 answered
 

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