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I found
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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: |
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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 |
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--What implant model, size, shape is best for me? |
--What are the risks or complications? |
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