Patient’s Name: ________________________________________ DOB:____________Phone: ___________________

O�ce Address/Location: __________________________________________________Phone: __________________

Referring Signature: ____________________________ ___________________ Date Ordered: _________________

Site of Previous Mammogram: ______________________________________________________________________

Screening Digital Mammogram

Bone Mineral Density DEXA (CPT 77080) - Please indicate Patient’s History:

Diagnostic Mammogram

MRI of the BreastsEvaluation of ImplantsEvaluation for Breast Cancer

2D (Standard Digital) 3D (Tomosynthesis)

2D (Standard Digital)

Screening Breast Ultrasound Dense Breasts, asymptomaticand negative mammogram.(If 40 or older)

3D (Tomosynthesis) Right

*must indicate site of concern on diagram*must indicate site of concern on diagram

Left Both

LT RT Bilateral

Personal History of Breast CancerLump - (if patient under 30 start with Breast Ultrasound - females only) Focal Point of PainSpontaneous Nipple DischargeCall Back From Screening Six Month Follow-UpOther _________________

Asymptomatic Personal History of Breast Cancer Breast Implants Other __________________

Procedures

DuctogramMRI Guided Breast BiopsyFine Needle/Cyst AspirationUltrasound Guided - Breast BiopsyStereotactically Guided Breast BiopsyNeedle Localization

Diagnostic Breast Ultrasound

Palpable LumpFocal Point of PainMass seen on MammogramOther ______________________

E x a m F i n d i n g s / S p e c i a l I n s t r u c t i o n s

IF ADDITIONAL IMAGING OR PERCUTANEOUS BIOPSY IS REQUIRED, PLEASE PROCEED WITH THESE EXAMS WHILE KEEPING ME INFORMED OF ALL RECOMMENDATIONS AND RESULTS.

MenopausalICD-10-CM

To Schedule Appointment Please Call: 714 784-1643

or Fax: 949 753-9030

Today’s Date:

_________

Hysterectomy with removal of ovaries Known Osteopenia or Osteoporosis

Fracture of any boneduring adult life

Hyperthyroidism

ONLINE APPOINTMENTS Now Available!

Access the portal at wcrc.com Use of Thyroid Medications History of Steroid Use

PATIENT LEFT PATIENT RIGHT

*must indicate site of concern on diagram

Santa Ana/Tustin: 1100-A N. Tustin Avenue, Santa Ana, CA 92705Newport Beach: 1441 Avocado Ave.,Suite 301, Newport Beach, CA 92660

Indicates Walk-in screening o�ered

***

[*]

Garden Grove: 9191 Westminster Ave, Garden Grove, CA 92844Orange: 230 S. Main Street, Suite 100, Orange, CA 92868

*Please have patient bring doctor’s order; If new patient, bring ALL prior outside mammograms & accompanying reports to appointment.* **Women with a recent breast cancer diagnosis or new breast issue are not eligible for Walk-in Screening Program**

Annual Screening Mammograms Now o�ered on a Walk-in Basis. No appointment needed if: No changes since last mammogram

Please see other side for instructions and map.

LOCATION OF CONCERN MUST BE NOTED ON REFERRAL.

PLEASE CHECK

WCRC_BREAST_COMPLETE_IRVINE_REV12192019VER1MC

[ ]Make an appointment for your next DEXA (Bone Density),Mammography, or Ultrasound exam online. Reserve a time

slot that is convenient for you. Download into your calendar.

Preparation for Digital Mammogram Examination:· No perfume, deodorant or body powder the day of the exam

· Please bring any previous mammogram �lms and reports

(if done at another facility).

· Please wear two piece clothing.

· Do not schedule one week before menstrual period.

Preparation for DEXA Exam:· Patients should not be scheduled within two weeks of any

diagnostic or CT exam utilizing

Barium, or any nuclear medicine exam.

· If possible, do not wear clothing with metal buttons or zippers.

Preparation for Breast Biopsy:· No aspirin or “blood thinner” one week prior to biopsy.

· Please consult your physician prior to discountinuing medications.

NO PREP NEEDED FOR BREAST ULTRASOUND OR CYST ASPIRATION.

BREAST IMAGING SCHEDULING GUIDELINES

Breastlink Women’s Imaging

Garden GroveDigital Mammography,

Breast Ultrasound, Breast Biopsy,DEXA

9191 Westminster Ave., Suite 210 Garden Grove, CA 92844

P:(714)784-1657F:(714) 891-6064

Breastlink Women’s Imaging

OrangeDigital Mammography,

Breast Ultrasound, Breast Biopsy,

Stereotactic Breast Biospy,Breast MRI, DEXA

230 S. Main Street, Suite 100Orange, CA 92868P:(714) 541-0101F:(714) 541-0450

Breastlink Women’s Imaging

Newport BeachMammography,

Ultrasound, Breast Biopsy

1441 Avocado Ave.,Suite 301Newport Beach, CA 92660

P:(949) 272-2095F:(949) 272-2096

Breastlink Women’s Imaging

Santa Ana/TustinDigital Mammography,

Breast Ultrasound, Breast Biopsy, Breast MRI, DEXA

1100-A North Tustin AvenueSanta Ana, CA 92705

P:(714) 543-9927 F:(714) 543-5883

WCRC_BREAST_COMPLETE_WIRVINE_REV01102019VER1MC

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LagunaBeach

Irvine

Fullerton

NewportBeach

HuntingtonBeach

DanaPoint

GardenGrove

YorbaLinda

SantaAna

LagunaHills

MissionViejoLaguna

Beach

Irvine

Fullerton

Newport

Costa Mesa

Beach

HuntingtonBeach

DanaPoint

GardenGrove

Orange

Tustin

YorbaLinda

SantaAna

LagunaHills

MissionViejo

La Mirada

5 Miles

10 Miles

ORANGECOUNTY

21

3 4

2

1

3

4