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Mammography Information & Consent Form

Benefits of procedure:

  • A vital tool for breast cancer screening, identifying abnormalities such as lumps or calcifications before they can be felt.
  • Can detect early-stage breast cancer, even in the absence of symptoms.

Risks of procedure:

  • Exposure to low-dose radiation, although the risk is minimal, and the benefits of early detection far outweigh the risks.
  • May cause temporary discomfort due to compression of the breasts during the procedure.
  • False positives or negatives are possible, requiring further tests for clarification.

PATIENT HISTORY: This information is required to aid the Radiologist (medical imaging doctor) in making an accurate diagnosis.

1. Are you having any concerns about your breasts?

If yes, please indicate below:

Name of Symptoms
Right Breast
Left Breast
Lump
Pain or tenderness
Nipple discharge
Swelling or discoloration
Other

2. Has a doctor ever diagnosed you with a breast problem?

If yes, please give details:

Diagnosis
When was the diagnosis?
Right Breast
Left Breast
Breast cyst
Breast fibroadenoma
Breast Infection
Breast cancer
Other

3. Have you ever had a medical procedure performed on your breast(s)?

If yes, please give the details below:

Name of Procedure
Description 
Institution Name
Right Breast
Left Breast
Breast biopsy 
Lumpectomy
Mastectomy 
Aspiration 
Breast implants
Breast reduction Removal of breast tissues
Other

3. Were you older than 30 years of age when you had your first child?

4. Have you breastfed in the last 3 months?

5. Have you ever been diagnosed with ovarian or any other cancer?

If yes, name the treatment

Family History

Do you have any first-degree relatives (mother, sisters, daughters) that have been diagnosed with breast cancer?

If yes, please state their relation to you and the age they were diagnosed.

WAIVER & CONSENT

  • I understand the information provided to me about the mammogram.
  • Additionally, I am aware that the Radiologist may recommend that I undergo additional mammography or other imaging studies.
  • I understand that the results from my breast imaging studies should be taken to my doctor, and it is my responsibility to follow up with my doctor and/or seek appropriate follow-up care.

Witness Confirmation

By clicking the "Confirm" button, you acknowledge that Apex Radiology has electronically witnessed this consent form. The date and time of submission are recorded and securely stored as part of your medical record.

Radiographer’s notes:

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