Cell: ▲ ▼ ▲ ▼ ▲ ▼ "Electronically signed"
Billing #: Phone: Fax: Additional Copies of Report:
Subject:
Creative Commons License Breast Imaging eForm, original by Dr. D. Page, is licensed under a GPL. Update V11_Jan5_2023 by Dr. John Yap.
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Choose specific Tickler reminder date
Quick picks: 2 wk 4 wk 8 wk   

1. Choose Hospital Site  

    Screening Info     Web Info

2. Location of previous imaging

Location of Mammogram:
See attached 
Fraser       Vancouver       Interior       Island       Northern 

Location of US:
See attached 
Fraser       Vancouver       Interior       Island       Northern 

2. Radiology follow up request

 Date of recent imaging Today      
Follow Up:
Mammo Lt 3 mo  6 mo  12 mo 
Mammo Rt 3 mo  6 mo  12 mo 
Mammo Bil 3 mo  6 mo  12 mo 
US Lt 3 mo  6 mo  12 mo 
US Rt 3 mo  6 mo  12 mo 
US Bil 3 mo  6 mo  12 mo 
US + Mammo Lt 3 mo  6 mo  12 mo 
US + Mammo Rt 3 mo  6 mo  12 mo 
US + Mammo Bil 3 mo  6 mo  12 mo 

3. Previous biopsies or surgeries    

Right       Left       Bilateral 

Excision biopsy       Needle biopsy       Mastectomy 

Date of procedure

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