3 Month Thermography Form
This form is for anyone with a 3 month follow up breast thermography appointment.
Our office is a green paperless office. We e-mail your Thermography Report to you once it is complete.
Only enter any changes since your last thermography appointment. If there are no changes then skip this page.
Breast Thermography Questionnaire
Males please continue to the next page, unless your breasts are your primary concern.
Have you recently had any of these breast symptoms:
If you were diagnosed with breast caner, please answer the following:
If you were diagnosed with other breast disease, please answer the following:
Breast biopsies or surgery:
I understand that the report generated from my images is intended for use by trained health care providers to assist in evaluation, diagnosis and treatment. I further understand that the report is not intended to be used by individuals for self-evaluation or self-diagnosis.
I understand that the report will not tell me whether I have any illness, disease, or other condition but will be an analysis of the images with respect only to the thermographic findings of the areas discussed in the report.
As required by the Privacy Regulations, Family Health Thermal Imaging & Detox may not use or disclose your protected health information except as provided in our Notice of Privacy Practices without your authorization.
I hereby authorize this office and any of its employees to use or disclose my Patient Health Information to the following person(s), entity(s), or business associates of this office: EMI, Electronic Medical Interpretations
Patient health information authorized to be disclosed: thermal images and related health history
For the specific purpose of: interpretation of said images
Effective dates for this authorization: appointment date through 7 yearsThis authorization will expire at the end of the above period.
I understand that the information disclosed above may be re-disclosed to additional parties and no longer protected for reasons beyond our control.
I understand I have the right to:
1. Revoke this authorization by sending written notice to this office and that revocation will not affect this office's previous reliance on the uses or disclosure pursuant to this authorization.
2. Knowledge of any remuneration involved due to any marketing activity as allowed by this authorization, and as a result of this authorization.
3. Inspect a copy of patient health information being used or disclosed under federal law.
4. Refuse to sign this authorization.
5. Receive a copy of this authorization.
6. Restrict what is disclosed with this authorization.
I also understand that if I do not sign this document, it will not condition my treatment, payment, enrollment in a health plan, or eligibility for benefits whether or not I provide authorization to use or disclose protected patient health information.
Office Policies Updated 9/1/2015
Our goal is to provide quality services in a timely manner. In order to do so, we implemented an appointment deposit policy. This policy enables us to better utilize available appointments for our clients. A nonrefundable deposit of $50 is required to make any appointment at our office. This $50 WILL be deducted from your total visit cost. The term nonrefundable includes cancelling/rescheduling in under 72 hours and no shows, please see policies below. Rescheduled appointments not falling in these two categories will not have to make a new deposit.
In order to be respectful of the needs of other clients, please call our office at least 72 hours in advance if you are unable to attend your appointment. Calling early in the day is appreciated. Rescheduling/cancelling early will give another client access to schedule an appointment sooner.
A ‘no show’ is someone who missed, was 20 minutes late or did not cancel/reschedule their appointment at least 72 hours in advance. No shows will be recorded in the client’s chart. If you fall in the no show category, then you will be asked to make a new deposit to reschedule.
Due to the fact all visits are prepaid, a $50 deposit will not be collected to schedule your appointments. Instead, if you do not call to cancel/reschedule at least 72 hours in advance or are considered a no show then you will lose that type of appointment(s) which is in question from your package.
All sales are final on products and service, no exceptions.
We strive to make our clients comfortable during their valued appointments. This includes the noise level. Please keep your cell phones on silent and kindly step outside our office to take a call. If you have children with you, then please bring something to keep them occupied that does not involve noise. All children must be accompanied by an adult throughout our office at all times, for their safety. We do have children’s books and prizes for good behavior!