Mammography History Form

Complete this before your appointment and your provider can be better prepared during their time with you.

Patient Information

This information will be sent to your provider and will be kept as part of your patient records.

Mammography Disclosure and Consent

You have the right, as a patient, to be informed about any diagnostic procedure that might involve even though minimal, any risks or complications. This disclosure is not meant to frighten or alarm you; it is simply an effort to make you better informed.
X-ray examination of the breast (mammography) is the most accurate method of detecting breast cancer. You should understand, however, that a mammogram is not 100% effective in detecting all breast cancers. Some cancers may be seen on the x-ray study and cannot be felt on physical examination. Other cancers can be felt on physical examination, but cannot be seen on the x-ray study. It is estimated that as many as 10% of cancers cannot be detected by mammograms in certain types of breasts. A negative or normal mammogram does not completely exclude the possibility of breast cancer. Additional views of your breast may be requested by the Radiologist. We may call you if this is necessary. It does not mean that your mammogram is abnormal. If you have not had a recent breast examination by a health professional prior to the mammogram, you must contact your doctor for a breast examination. Please remember to perform your monthly breast self-examination and notify your doctor of any changes, thickening, or lumps that you might encounter.
Compression of the breast is necessary to obtain the best possible views of the inside of your breasts with the least amount of radiation. You might be wondering why such vigorous compression is necessary. This kind of compression, while briefly uncomfortable, is better for you in the long run. It helps us to take much clearer x-rays of your breast with much less radiation. It's important for you to realize that: compression isn't dangerous; it doesn't damage breast tissue in any way and compression produces no long-term discomfort

Visitor Screening Questionnaire

Please review to ensure the details are correct before completion.

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