Patient & Appointment InformationName

Address

City Province Postal Code

Home Phone Other Phone

DOB Male Female

AHC#

Clinical History

Clinical History

Breast Imaging

Bone Mineral Densitometry

Appt. Date Time CDC Site

Previous Mammogram

Date

Location

History Type of Exam

Initial Assessment

Follow Up

Date

Location

Current Medications for Treatment?

Other Signi�cant History

Family History of Breast Cancer

HRT Specify # Years

Prior Diagnosis of Breast Cancer

Previous Breast Biopsies

Breast Implants/Reduction

Pain

* Procedure availability & hours of operation vary by CDC location CanadaDiagnostics.ca

Lump or Thickening

Nipple Discharge - Bloody

Nipple Discharge - Non-Bloody

Dimpling or Nipple Retraction

Change in Size, Shape, or Colour

Previous Breast Cysts

Previous Mammo or US Finding Follow-up

Positive for BRCA1 or BCRA2 Gene

Other

PhysicianReferring Physician

Clinic

Phone

Fax

Copy to Dr.

Fax Copy to Dr.

PRAC ID

Signature

Right Left

General UltrasoundPatient has been examined and found to have the following:

No breast abnormality or breast symptom

Ultrasound

Cyst Aspiration

Core Biopsy

Diagnostic MammographyScreening Mammography

General UltrasoundWeight Limit: 260 LbsUnable to accommodate patients inwheelchairs unless patient has attendant

Bone Mineral Densitometry

Comments

Height

LMP

Weight

Tech

Breast Centre Radiology - Callingwood329-6650 177 St NW Edmonton, AB T5T 4J5 Phone: 780.444.0472 Fax: 780.481.8321

Breast Centre Radiology - 109 St7121 109 St NW Edmonton, AB T6G 1B9 Phone: 780.434.9147 Fax: 780.436.7650

Please do not wear the following:- Deoderant- Perfume- Scented hair/body products

:

dd/mm/yy

Phone: 780.341.6000Toll free: 1.877.420.4CDC (4232)Toll free Fax: 1.877.919.3291Email: appointments@CanadaDiagnostics.caOnline Request: CanadaDiagnostics.ca

Breast Centre Radiology

dd/mm/yy

MAMMOGRAPHYThis exam requires that you DO NOT wear deodorant or body powder the day of the exam. If you have premenstrual tenderness in your breasts, it is advisable to schedule your appointment after it has subsided. Also AVOID ca�eine intake beginning two days prior to your exam.

BONE MINERAL DENSITOMETRYPlease DO NOT take any MULTIVITAMINS, CALCIUM, or IRON BEFORE your exam. You may take them AFTER your exam.

Exam Preparation

Locations

• Arrive 15 minutes prior to your exam unless notified otherwise Our clinics are scent free - Please refrain from wearing scented products•

• Please bring an adult to supervise children under the age of 12

PLEASE BRING THIS REQUISITION FORM & HEALTH CARE CARD TO YOUR EXAM

Additional services provided at 4 Edmonton & Sherwood Park locations. For a list of all services and locations, please visit CanadaDiagnostics.ca

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7121 109 St NWPhone: 780.434.9147Fax: 780.436.7650

Women’s ImagingUltrasound (Breast)MammographyBone Mineral Densitometry

1Breast Centre Radiology - 109 St

329-6650 177 St NWPhone: 780.444.0472Fax: 780.481.8321

Women’s ImagingUltrasound (Breast)MammographyBone Mineral Densitometry

2Breast Centre Radiology - Callingwood

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To book an appointment, please call 780.341.6000 toll free 1.877.420.4CDC (4232)fax this form to 1.877.919.3291, email this form to appointments@CanadaDiagnostics.ca,

or request an appointment at CanadaDiagnostics.ca