This PS Informed Consent Has Merit!

[Guest guest]

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

your physician.

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Statement for Physician:

I, ____________________________, surgeon and physician ,for

_____________________, patient, hereby guarantee that breast implants

do not cause breast cancer, brain tumors, lung tumors, rheumatological

diseases, and respiratory disorders.

I understand that breast implants have never been proven safe for

human use.

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 without

passing along that refund to the patient.

I have never received medical reimbursement from the manufacturere of

a breast implant without passing along that reimbursement to 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.

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Signature of Surgeon Date

_________________________

Signature of Witness

_________________________

Notarized by

Martha Murdock, DirectorNational Silicone Implant Foundation | Dallas Headquarters"Supporting Survivors of Medical Implant Devices"4416 Willow LaneDallas, TX 75244-7537