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REQUEST FOR MAMMOGRAPHY SERVICES Breast Imaging Center of Excellence Ordering care provider Patients name DOB *Best daytime phone number to contact patient Alternate Date last clinical breast exam
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Who needs breast imaging center of:

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Women who are experiencing breast-related symptoms, such as lumps, pain, or changes in the breast tissue.
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Individuals with a family history of breast cancer or other breast-related conditions.
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Women above a certain age, as recommended by healthcare guidelines, who should undergo regular breast screenings for early detection and prevention.
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Patients who have been referred by their healthcare provider or primary care physician for further investigation or consultation regarding breast health.
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Individuals who have previously had breast surgery or treatments and require follow-up imaging or monitoring.
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Patients with a known breast abnormality identified through previous screenings that require further evaluation or diagnostic tests.
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Women participating in breast cancer research studies or clinical trials that involve imaging and monitoring of breast health.
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Individuals seeking a second opinion or additional perspective on their breast health from specialized breast imaging centers with the latest technology and expertise.
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Breast imaging center is specialized in providing services related to detecting and diagnosing breast abnormalities.
Breast imaging center of is required to be filed by healthcare facilities or centers offering breast imaging services.
The breast imaging center of can be filled out by providing accurate and detailed information about the center's activities, services, and compliance with regulations.
The purpose of breast imaging center of is to ensure transparency and accountability in the operations of breast imaging centers.
The breast imaging center of must include information such as the types of imaging services offered, number of procedures conducted, qualifications of staff, and quality assurance measures.
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