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Co. uk 42-52 Nottingham Place London W1U 5NY PLEASE SEND ALL RELEVANT IMAGING WITH THE PATIENT Patient Name. Present clinical findings please mark in lesions and site of tenderness etc. Radiographer. Rad dose. Mammography Request Form Please fax this form to 0207 908 2010 For appointments/enquiries please call 020 7908 2000 Option 4 Email appointments londonbreastinstitute. Examination required DoB. /. / Hospital No X. Address. Daytime Tel. Mobile. Email Females 12-55yrs Clinical...
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How to fill out mammography request form
How to fill out mammography request form
01
Read the instructions on the mammography request form carefully.
02
Start by providing your personal information, such as your name, address, and contact details.
03
Fill in the medical history section by answering questions related to previous surgeries, family history of breast cancer, and any current symptoms or concerns.
04
Indicate whether you have any breast implants or previous mammography results that need to be compared.
05
Ensure all necessary sections are completed, including the date of your last menstrual period, if applicable.
06
If you have been referred by a healthcare professional, include their name, clinic or hospital, and contact information.
07
Double-check that you have provided accurate information and haven't skipped any required fields.
08
Review any additional instructions or comments provided by your healthcare provider.
09
Submit the completed mammography request form to the designated healthcare facility or department.
10
Wait for further instructions or a scheduled appointment for your mammography screening.
Who needs mammography request form?
01
Women who are aged 40 and above and have never had a mammogram before.
02
Women who have a family history of breast cancer.
03
Women who have noticed any changes or abnormalities in their breasts.
04
Women who have previously had a breast biopsy or other breast procedures.
05
Women who have been referred by their healthcare professional due to specific concerns or symptoms.
06
Women who are undergoing regular breast cancer screening or follow-up.
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