To Be Completed By Administrator

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

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2. Last Name of Person Completing this Form (enter last name of person only)

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3. Subjects who meet all of the following criteria are eligible for enrollment as study participants (YES answer required to all to be eligible)

  Yes No
Subject is female, aged 18 to 80
Subject currently has one or two silicone gel breast implant(s) implanted between January 1, 2000 and December 31, 2015
Subject has access to her breast surgery record or device card for her current implants
Subject is willing and able to undergo an ultrasound scan to screen for rupture of her silicone gel breast implant(s)
Subject is willing and able to complete pre- and post-screening surveys

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4. Subjects who meet any of these criteria are NOT eligible for enrollment as study participants (NO answer required to all to be eligible)

  Yes No
Subject is male 
Subject is under the age of 18 or over the age of 80
Subject received her current silicone gel breast implant(s) prior to January 1, 2000 or after December 31, 2015
Subject has a known allergy to ultrasound gel

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5. Based on the answers above, subject is eligible for enrollment into the study

0 of 28 answered
 

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