IMPLANT REMOVAL FORM

BRADLEY K. BECKER, D.O., P.L.L.C.

Cosmetic Surgery, Plastic & Reconstructive Surgery
18555 N. 79th Ave.,Suite B-102
Glenda le, AZ 85308
Ph:602.610.9111
Fax: 623.471.5180

IMPLANT REMOVAL AND DISPOSAL FORM

I,

DOB:

consent to the removal of my implants.

The reason for this procedure is:

and will be performed by Bradley Becker, D.0., P.L.L.C. and his designated assistant(s).

I understand that after removing the implants, they are cleaned but not sterilized.

I understand that no matter what kind of material the implant is made of or where it existed inside the body, all implants, once extracted, are treated as medical waste and are considered a biological hazard. They contain blood or other bodily fluids and matter, they must never be disposed of with municipal trash.

I understand, I am solely responsible for the disposal of the implants in safe way.

I understand that Dr. Bradley Becker and/or Surgical Center are no longer liable for these implants after removal.


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