Get Mammogram Order Form

Filling out the Mammogram Order Form online is a crucial step in ensuring timely and accurate screening services. This guide provides clear, step-by-step instructions to help users complete the form efficiently and correctly.

Follow the steps to complete the Mammogram Order Form.

1. Click ‘Get Form’ button to access the Mammogram Order Form and open it for editing.
2. Begin by entering the ordering care provider's name in the designated field, followed by the date of the request.
3. Include the name of the person who should receive a copy of the report, filling out that section accordingly.
4. In the patient’s details section, input the patient’s name and date of birth. Then, provide the best daytime phone number for contact, followed by an alternate number if available.
5. Specify the best weekday and/or time for scheduling the appointment, ensuring it aligns with the patient's availability.
6. Indicate the date when the last clinical breast exam was performed. This information can assist in scheduling.
7. Choose the type of mammogram being requested: a screening mammogram (indicating bilateral or unilateral as necessary) or a diagnostic mammogram, also indicating if implants are present.
8. If applicable, select ultrasound and indicate the reason using the provided options, marking the specific location on the diagram for clarity.
9. In the 'Indication' section, mark any relevant symptoms or concerns, using diagrams provided to illustrate specific areas when necessary.
10. Ensure the provider's signature is present in the required field to authenticate the request.
11. Review the breast history section and mark any relevant past medical history, such as mastectomy or lumpectomy, and note any familial breast cancer history.
12. Address any special requirements by indicating if a language interpreter is needed and if the patient has special needs.
13. Remind the patient of important notes about preparation for the mammogram, such as avoiding deodorant and bringing necessary identification and insurance information.
14. Finally, ensure to fill out the appointment scheduling details, including the date and time scheduled.
15. After completing the form, save changes, and download, print, or share the form as required.

Complete your Mammogram Order Form online today to ensure timely access to essential healthcare services.