phone: 780.341.6000 breast centre radiology toll free: 1 ...€¦ · city province postal code home...
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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: [email protected] 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
1
2017
.V1
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 [email protected],
or request an appointment at CanadaDiagnostics.ca