I found it on ImplantInfo by Nicole!
Bring this form to your doctor and you could
win a $250 Victoria's Secret Gift eCard*
(print this page as is or as a PDF file - click here for an Adobe PDF file)
  *Print & fill out this form & give it to your surgeon at your next visit.  Have your doctor initial, sign or stamp it.  Then, fax it to 888-899-3114.  I'll verify your visit with the surgeon and enter you in our drawing to win a $250 VS Gift Certificate (Next drawing August 1st!)

Your Name:          __________________________________   

Your email:          __________________________________

Your Phone:       ___________________________________

Your Address:   ___________________________________

Surgeon Name:   __________________________________

Surgeon Initial or Stamp Here: _____________________

Consult Date:     ___________________________________    

Information to give your surgeon:

My age: ____________

My height: _____ and weight _______

I have breastfed _____ children.

I think my current bra size is: ___________

My ideal bra size would be: ___________

I have pictures to show you: __ yes ___ no

I have had surgery before ___ yes ___ no
 
Questions for my plastic surgeon:

--What implant model, size, shape is best for me? 
--What incision approach do you recommend? 
--Will my implants be over or under the muscle?
--Do I need a lift or other correction? 
--May I see pictures of your patients?
--Do you have any patients I can contact?
--How long before I can work, exercise, etc? 
--Will I be able to breastfeed in the future?
 

--What are the risks or complications?
--What is the total cost of the procedure?
--What financing arrangements are available?
--What are your policies for revision? 
--What costs are involved, if any?
--What warranty coverage will I have? 
--Will any of my choices void the warranty?
--Is your operating facility certified?

THANK YOU FOR SPONSORING IMPLANTINFO BY NICOLE!

To contact Nicole and ImplantInfo.com, please email nicole@implantinfo.com or fax 888-899-3114