Prosthetic Urology Implant Identification Card and User Guide Request Form

Congratulations on your decision to receive a Boston Scientific Men’s Health implant

_{* Denotes required field}

First Name:*

Last Name:*

Street Address:*

City:*

State*

ZIP:*

Phone:*

Email Address:*

Your Implanting Urologist:

Procedure Date:

Device Implanted:*

AMS 700™ Penile Implant (ID card and user guide will be sent)

AMS Ambicor™ Penile Implant (ID card and user guide will be sent)

Spectra™ Penile Implant (ID card and user guide will be sent)

Tactra™ Penile Implant (ID card will be sent)

AdVance™ or AdVance™ XP Male Sling (Post-procedure guide will be sent)

AMS 800™ Artificial Urinary Sphincter (ID Card and user guide will be sent)

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