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Short Survey

This form will be sent directly Rebecca. These surveys will not be posted, I am collecting the data for research purposes. Your name and address is for my information only, please include it in case I need to contact you. Thanks!


Age:
Height: 
Weight: 
Location of Incision 
Are you happy with this location?

Implant cc size?: 
Before size: 
After size: 

How long have you had your implants?: 
Do you have Saline or Silicone? Saline Silicone
Round or Anatomical? Round Anatomical
Are your implants under or over the muscle? Under Over
Textured or Smooth? Textured Smooth
How would you rate the pain: 
Overall, are you happy with your implants? Yes No
Would you recommend your surgeon?: Yes No
Surgeon's Name? 

Surgeon's city & state? 

Comments about your surgeon? 

Your Name: 
Your Email: 
May we add your comments about your doctor to our web site?
If yes, may we use your first name and/or email?


 

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All About Breast Augmentation and Breast Implants Plastic Surgery Resource by Rebecca.
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