Data for Implant Truth Survivors Committee
Completing this form assists us to gather information about the number of women around the world who have or had breast implants and have suffered adverse effects.

Please provide as much detail as possible.

You may contact us at titscommittee@gmail.com with questions, comments or concerns.

Sincerely,

The Implant Truth Survivors Committee
Email address *
First name *
Your answer
Last name *
Your answer
Street address (include apartment number if applicable) *
Your answer
City *
Your answer
State or Country *
Your answer
Zip or Postal Code *
Your answer
Best email address *
Your answer
Best phone number *
Your answer
Implant date and year *
Your answer
Doctor who did your implant surgery - please include mailing address, phone and email if you have it *
Your answer
Do you have your medical records for implant surgery? *
Brand of implant (If not known use "unknown") *
Your answer
Have you had your implants removed? (explanted) *
Date and year of explant if implants have been removed - if not applicable use "NA" *
Your answer
If you have had more than one set of implants please list previous surgeries here and include date of implant, manufacturer, surgeon:
Your answer
Do we have your permission to provide this information to the FDA and/or an attorney representing the interests of The Implant Truth Survivors Committee? *
By submitting this form I understand that my information will not be released without my consent except for as specified to the FDA and/or an attorney working in collaboration with The Implant Truth Survivors Committee. *
By typing my name below I acknowledge and understand the use of this information and that I am providing permission for this use as described. *
Your answer
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