Center For Breast Care Referral Form
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1Center for Breastcare
APPT DATE/TIME: _________________________
q
6335 Hospital Parkway Suite 106, Johns Creek, Ga. 30097
NAME: (Last, First) __________________________________________________________
DOB: _________________________________________________________________________
PHONE: _____________________________________________________________________
Diagnosis: __________________________________________________________________
_______________________________________________________________________________
Please indicate whether patient would like 2D or 3D examination
PLEASE MARK AREA OF CONCERN
SCREENING MAMMOGRAPHY (ASYMPTOMATIC)
q
Bilateral
Right
Left
Implants
q
q
q
q
(performance of additional diagnostic mammographic
views and/or breast US if medically necessary)
12:00
12:00
DIAGNOSTIC MAMMOGRAPHY (SYMPTOMATIC)
q
Bilateral
Right
Left
Implants
9:00
3:00 9:00
3:00
q
q
q
q
(performance of breast US if medically necessary)
BREAST ULTRASOUND (SYMPTOMATIC)
q
Bilateral
Right
Left
6:00
6:00
q
q
q
(performance of diagnostic mammogram if
RIGHT
LEFT
medically necessary)
MRI
q
BONE DENSITOMETRY
q
Breast with and/or without contrast
q
Breast Implants
q
History: ________________________________________________
(performance of diagnostic mammogram and/or
breast US if medically necessary)
Menopause
q
Biopsy
q
Premature menopause
q
performance by:
Stereotactic or Ultrasound
Osteoporosis
q
History: ____________________________________________________________
Pathologic fracture-vertebrae
q
Abnormal mammogram follow up
q
Long term use of steroids
q
Lump or Mass in Breast
q
Other: ______________________________________________
q
Pain/tenderness in breast
q
Skin/nipple changes/Discharge
q
Change in size/shape of breast
q
Other: _____________________________________________________
q
Patient Preparation Instructions For Exams:
Due to the nature of your appointment, children will not be allowed in the exam room.
Procedure Instructions:
For your comfort, please wear two piece clothing.
Please do not wear powder, perfume, lotion or deodorant in the breast or underarm area. This interferes with the quality of your images.
Please be sure to bring previous mammogram images/reports from other healthcare facilities. We will need them for comparison.
Bone Densitometry:
Wear loose comfortable clothing with no metal snaps or zippers.
PHYSICIAN NAME (PRINT): _________________________________________________________ PHONE: ___________________________ FAX: _____________________________
PHYSICIAN SIGNATURE: _______________________________________________________________________________ DATE/TIME: ________________________________________
PHYSICIAN'S ID #: ____________________________ NPI #: ____________________________ CC REPORT TO: _________________________________________________________
105298
REQUES105298 11/13
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Parent category: Medical