Follow the steps to fill out the mammography request form online:

1. Press the ‘Get Form’ button to acquire the mammography request form and open it in your preferred editor.
2. Begin with the ‘Referring Doctor’ section, where you need to enter the name of the doctor referring the patient for examination.
3. In the ‘Patient Details’ section, fill out the patient’s surname, first names, date of birth, clinic number, and contact address.
4. Provide the patient’s telephone number in the designated fields. Make sure to include both home and mobile numbers if possible.
5. For female patients aged 12-55 years, indicate the date of the last menstrual period (L.M.P.) in the specified field.
6. Answer the question regarding the possibility of pregnancy by ticking the appropriate box (Yes or No). Be sure to note if the patient uses a chair, stretcher, or is ambulatory.
7. In the ‘Clinical History’ section, provide a full medical history, as required by the Ionising Radiation (Medical Exposure) Regulations.
8. In the ‘Examination Requested’ section, indicate the reason for the mammography by selecting the appropriate option from the provided choices.
9. If applicable, answer the specific question that needs to be addressed by the examination in the space provided.
10. Include the date and sign the form to validate the request, along with indicating the preferred radiologist if desired.
11. Before submission, ensure all fields are completed accurately. Users may then save changes, download, print, or share the completed form as necessary.

Complete your mammography request form online today for a timely appointment.