I understand that this patient brochure "Important Information for Augmentation/Reconstruction Patients About Mentor MemoryGel™ Silicone Gel-filled Breast Implants"  is intended to provide the information regarding the risks and benefits of silicone gel-filled breast implants, both general and specific to Mentor's MemoryGel™ products. I understand that silicone breast implant surgery involves risks and benefits, as described in this brochure. I also understand that the long-term (i.e.,10 year) safety and effectiveness of silicone gel-filled breast implants continue to be studied.  I understand that reading and fully understanding this brochure is required, but that there also must be consultation with my surgeon.  By circling the correct response and signing below, I acknowledge:

  Y / N   I have had adequate time to read and fully understand this brochure;

  Y / N   I have had an opportunity to ask my surgeon any questions I may have about this brochure or any other issues related to breast implants or breast implant surgery;

  Y / N   I have considered the alternatives to silicone breast implants and have decided to proceed with silicone breast implant surgery;

  Y / N   I have been advised to wait at least 1-2 weeks after reviewing and considering this information, before scheduling my silicone breast implant surgery; and

  Y / N   I will retain this brochure, and I am aware that I may also ask my surgeon for a copy of this signed acknowledgment.

• ____________________________
• Patient (PRINT NAME)
•  
• ____________________________      _____________________
• SIGNATURE OF PATIENT*                      DATED:

*A patient must be at least 22 years old for primary and revision breast augmentation with silicone breast implants

By my signature below, I acknowledge that:

• My patient has been given the opportunity to ask any and all questions related to this brochure, or any other issues of concern;
• All questions outlined above have been answered "Yes" by my patient;
• My patient has had a waiting period of at least 1-2 weeks before making her final decision; and
• Documentation of this Informed Decision will be retained in my patient's permanent record.
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• _________________________________                      ________________________
• SIGNATURE OF SURGEON                                             DATED:

Important  Information  About  Implant  Breast  Enlargement

Important Information about Silicone Breast Implant Use