Tucson Plastic Surgeon Raad Taki MD
Excellence in Plastic Surgery
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Acknowledgment of Informed Decision
Acknowledgment of Informed Decision
I understand that this patient brochure, “Important information for Augmentation Patients About Mentor MemoryGel Silicone GeI-fiIIed 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 checking the correct response and signing below, I acknowledge:
I have had adequate time to read and fully understand this brochure
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Yes
No
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
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Yes
No
I have considered the alternatives to silicone breast Implants and have decided to proceed with silicone breast implant surgery
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Yes
No
I will retain this brochure, and I am aware that I may also ask my surgeon for a copy of this signed acknowledgment
*
Yes
No
Name
*
First
Last
I have read, accept and acknowledge receipt of this notice.
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Initial Here
Member, American Society of Plastic Surgeons
Member, American Society for Aesthetic Plastic Surgery
Call us at 520-881-3232
4580 East Camp Lowell Drive - Tucson, Arizona - 85712