Please read the following instructions carefully.

In order to assure that we are receiving valid requests, we must perform our due diligence in this process. Sadly – there have been many who have requested funding with no intention for using funding for the specific purpose. To avoid this from happening here – we do require a few things to make sure the women who need the help – get help.

  1. You MUST be registered with us as having breast implants. Please use this form to do so>> Data Collection Registration  
  2. IF YOU ARE NOT REGISTERED YOUR INQUIRY FOR FINANCIAL ASSISTANCE WILL NOT BE PROCESSED. Please see #1.
  3. This is a pre-qualification screening tool to help us better assist you with accessing resources for breast implant removal. Once we receive your request we will acknowledge it’s receipt and let you know next steps to enter the formal application process.
  4. This is for women in the USA only.
  5. This form MUST be completed in order to access the application.
  6. All information submitted here will be kept in strictest confidence.

Please mark the boxes below that are applicable to your situation.

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