Breast Implant Contact Form    NAME: ADDRESS: (Optional) PHONE NUMBER: (Optional) BREAST IMPLANT QUESTIONS: Approximate Date of 1st Breast Implant Surgery:   Brand Name of 1st breast implant   Implant Model Number :   Implant Lot Number:   Do you have "Proof" of the brand of implant you received?   YES NO -------- If so, what type of proof? (Example, copy of surgery report that lists brand, letter from doctor, etc.   Have one or more of your implants been removed?   YES NO -------- Date Implant Removed   Did you receive new implants?   YES NO -------- If so, what was brand of implant?   "Do you have proof of this implant?"   YES NO -------- Have any of your implants ruptured?   YES NO -------- If so, what Implant Brand Ruptured?     List other implant surgeries if applicable and the brand of implant. Have you registered with the earlier MDL-926 Class Action? YES NO -------- If so, did you receive any money and how much? Have you registered with the Dow Corning Class Action? YES NO -------- If so, has your Dow proof been accepted?   YES NO -------- If so, did you receive any money and how much?   Do you have an existing attorney?: YES NO -------- Have you noticed any of the symptoms listed on the right, after you received your breast implants?  Check all that apply: Arthritis Breast Deformity Chills/Sweats Depression Fever Hair Loss Headaches Joint Pain Low Disease Resistance Memory Loss Muscle Weakness Weight Gain Weight Loss None Have you ever been treated for any of the above?: YES NO -------- Are you having any unexplained symptoms that you are concerned about? Are you having problems with the claims board? If yes, please explain. Name: Email: Subject: Comments:      Please enter the security code you see above.   Security Code:         ( indicates a required field)