Get the free Breast Imaging Request - North State Radiology

Breast Imaging Request Patient Name: A division of North State Radiology 1720 Esplanade Chico, CA 95926 530 8980502 FAX 8980533 chicobreastcare.com Home Phone: DOB: Appointment Date: Time: Prior Mammogram

How to fill out breast imaging request

How to fill out a breast imaging request:

1. Locate the breast imaging request form, which can usually be obtained from your healthcare provider or imaging center.
2. Fill in your personal information such as your full name, date of birth, and contact information.
3. Provide your medical history, including any relevant past or current medical conditions, surgeries, or medications.
4. Indicate the reason for the breast imaging request, such as a routine screening, follow-up on a previous abnormality, or specific symptoms you may be experiencing.
5. Specify the type of breast imaging you are requesting, whether it is a mammogram, ultrasound, MRI, or any other type of imaging.
6. Ensure that you provide accurate information regarding your insurance coverage or payment options.
7. If you have any known allergies or have had a previous adverse reaction to contrast dye or imaging procedures, make sure to include this information.
8. Sign and date the form to confirm that the information provided is accurate and complete.
9. Submit the completed breast imaging request form to your healthcare provider or imaging center for processing.

Who needs a breast imaging request:

1. Women who are due for their routine mammogram as part of their regular breast cancer screening.
2. Individuals who have found a lump or experienced an unusual breast symptom and require further evaluation.
3. Patients who have had a previous abnormal imaging finding and need follow-up imaging to monitor any changes.
4. Women or men with a higher risk of developing breast cancer due to family history, genetic mutations, or previous diagnoses.
5. Individuals who have been recommended or referred for breast imaging by their healthcare provider as part of their comprehensive medical care.
6. Post-surgical patients who require imaging to assess their breast tissue after a procedure, such as a breast augmentation or lumpectomy.
7. Patients participating in clinical trials or studies that involve breast imaging as part of the research protocol.
8. Individuals who have experienced trauma or injury to the breast and require imaging to assess potential damage.
9. People with certain medical conditions or treatment plans that necessitate regular breast imaging, such as individuals undergoing hormone replacement therapy or radiation therapy.

Remember to consult with your healthcare provider or imaging center for specific guidelines regarding who needs a breast imaging request and how to fill out the form accurately.

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