Patient Consent and Registration Form

All fields must be completed on the registration form in order for the form to be submitted.

Thank you for choosing POLYTECH implants for your breast surgery. Please find below the Patient Promise Consent and Registration Form
By completing the registration form, you will be covered for 2 years following the insertion of your implants. Before the 2nd year anniversary of your treatment, you will be contacted by Surgical-Aftercare-Solutions and offered the opportunity to extend your cover for a further 1 year period.

Patient Promise Warranty Brochure

Policy Number: REUKG1400075-QMED
PATIENT INFORMATION
Date of Birth:*
Name*
Title First Name Surname
Address*
Street Address Address Line 2 City Postcode
Telephone:
Email*
Consent Section:
- If you do NOT wish to be contact by “SAS” to be given the option to renew your insurance coverage please tick this box.
Patient Declaration:*
- I declare to the best of my knowledge and belief that the information given on this form is true and complete
Date completed:*
HOSPITAL INFORMATION
SURGEON'S DETAILS
Name*
First Name Surname
Hospital Address*
Street Address Address Line 2 City Post Code
Email
Telephone:
Date of Implantation:*
DETAILS OF IMPLANTATION
Left Breast
Product code:
Serial Number
Left breast serial number
Right Breast
Product code:
Serial Number
Right breast serial number:
SAS is an FCA Introducer to DIP, is authorised and regulated by the Financial Services Authority. Registered in England No: 05734966
Name
This field is for validation purposes and should be left unchanged.

Please contact your surgeon if you require assistance completing this form.

Further Information

The Patient Promise warranty provides full comprehensive assurance against the potential complications of your breast augmentation or reconstruction surgery when using Polytech breast implants.

This insurance policy is provided by Surgical-Aftercare-Solutions (SAS) and is underwritten by City & Commercial. The policy will meet any remedial treatment fees in respect of clinically required revision surgery up to a maximum of £1,500 per implant or £2,500 per B-Lite® implant. The following potential complications are covered by this warranty.

Capsular Contraction Baker Grade III or IV
Dislocation
Rotation
Rupture
Haematoma (Requiring Treatment)
Seroma (Requiring Treatment)
Post Operative Infection
MRSA Infection
BIA-ALCL

Your surgeon or their clinical team can provide you with information on these potential complications.

In order to administer this service we need to collect certain information from you. Surgical-Aftercare-Solutions and Q Medical Technologies Ltd, are obliged to treat personal data as strictly confidential. Your contact information will be used solely to administer the Patient Promise warranty. All other data will be used exclusively for statistical analysis and to provide you with the service requested. Your data will NEVER be sold or passed onto a third party.

Patient Promise Warranty Brochure

PATIENT INFORMATION

HOSPITAL INFORMATION

SURGEON'S DETAILS

DETAILS OF IMPLANTATION

Further Information