Making An Appointment

Name* required

DOB* required

Contact phone* required

Email* required

Postcode

Medicare number* required

Private health insurance Y/N and details* required
YesNo

When did you have implants?

Where did you have your procedure?

Name of surgeon

Name of clinic

Last follow up by treating doctor

Have you had your breast and/or breast implants checked in the last 12 months
YesNo

Location of check

Do you know the type of implant you have?
RoundAnatomicSmoothTextured

Size

Implant manufacturer

Serial number, lot number

Do you have a warranty for your implant?
YesNo

Have you noticed any of the following
Change in positionPainChange in shape of breast(s)SwellingRipplingDouble bubble