When given that wonderful "Informed Consent" to sign, give this to your physician.

Statement for Physician:

I, ______________________________________________, surgeon and physician, for ____________________________, patient, hereby guarantee this product will not last longer than five years. It may rupture within a year if I cut the implant with a scapel, nick it with a needle, or break the fill tube.

Furthermore:

Breast implants do not cause breast cancer or any other disease known to man.

I understand that breast implants have never been proven safe for human use.

I understand that breast implants have never received FDA approval.

I have never received breast implants at a reduced price from a breast implant manufacturer.

I have never accepted any incentive from a breast implant manufacturer to promote the safety and use of their product.

I have never received a refund on returned breast implants and charged the patient.

I have never been entertained by a breast implant manufacturer representative as an inducement to use their product.

Should any of these above events be proven true, I will re-imburse my patient or her family for the full amount of surgery, including hospital and anesthesia costs. I will also place a full page add in the newspaper of the patient's choice exposing the dangers of breast implants.

_______________________________________________________

Signature of Surgeon

Date

_________________________

Signature of Witness

_________________________

Notarized by