PIP Implant Analysis

Thank you for agreeing to send your intact explanted PIP implant/s for analysis.  The results and findings will be used for general research purposes and to better understand the nature and effects of fraudulent PIP implants.  The details of any published studies will be made available on publication.  Individual results can be obtained by email if you confirm your email address in the box at the end of the form.  This form should be printed, signed and sent with a completed Symptom Survey to the laboratory with explanted PIP Implant/s for analysis.

You can download the Symptom Survey at http://pipactioncampaign.org/Symptom%20Survey%20web.pdf

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Name *
Email contact *
Date of Birth *
This is so the age at which you had your original surgery and at the time of PIP removal surgery can be recorded.
Year of Original PIP Surgery *
Year of PIP Removal Surgery *
Did you have Implants for Medical Reasons? *
Reason for explant ? *
Right Side: Size, Model, Lot and Serial Number
Right Side : Implant Condition on Removal
Clear selection
Left Side: Size, Model, Lot and Serial Number
Left Side: Implant Condition on Removal
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Did you experience any symptoms with PIP Implants? *
Please see and complete the Full Symptom Survey
Have your symptoms, if any, resolved since having PIP implants removed? *
Please see and complete the Symptom Survey
Please rate your health and state of well-being BEFORE PIP implant removal *
Healthy & Unconcerned
Unwell & Anxious
Has your health and state of well-being improved AFTER PIP implant removal? *
Not at all
Full return to health
Explanted Intact PIP Sample being sent for analysis *
Please Sign Here ... when the form is printed
To receive details of individual results
Please confirm your email here
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