Forms - Thermography

Below you will find the forms for thermography services. Please download and bring them filled out to your next visit. If you are a follow up patient please refer to "Follow Up" for your thermography service below.

• Breast Thermography
• Breast Thermography Follow-up
• Male Full Body Thermography
• Male Full Body Thermography Follow-up
• Female Full BodyThermography
• Female Full BodyThermography Follow-up
• Lower Body Thermography
• Lower Body Thermography Follow-up
• Region of Interest Thermography
• Region of Interest Thermography Follow-up
• Male Upper Body Thermography
• Male Upper Body Thermography Follow-up
• Female Upper Body Thermography
• Female Upper Body Thermography Follow-up
• Anthem ABN Waiver

 

Breast Thermography

1. Patient Data
2. Receipt of Privacy
3. Financial Policy
4. Advanced Beneficiary Notice
5. General Adult History
6. Schedule of Medications and Supplements
7. Diagnoses and Problems
8. Thermography Consent
9. Thermography History
10. Thermography Breast Questionnaire
11. Anthem ABN Waiver

If you had or have breast cancer please fill out additionally:

1. Thermography Extended Breast Questionnaire
2. Thermography Detailed Extended Breast Questionnaire

Breast Thermography Follow-up Patients

If you are a follow up patient please download the form below and bring it filled out to your next visit.

1. Thermography History
2. Thermography Breast Questionnaire

 

Male Full Body Thermography

1. Patient Data
2. Receipt of Privacy
3. Financial Policy
4. Advanced Beneficiary Notice
5. General Adult History
6. Schedule of Medications and Supplements
7. Diagnoses and Problems
8. Thermography Consent
9. Thermography History
10. Thermography Full Body Questionnaire
11. Anthem ABN Waiver

Male Full Body Thermography Follow up Patients:

If you are a follow up patient please download the form below and bring it filled out to your next visit.

1. Thermography History

 

Female Full Body Thermography

1. Patient Data
2. Receipt of Privacy
3. Financial Policy
4. Advanced Beneficiary Notice
5. General Adult History
6. Schedule of Medications and Supplements
7. Diagnoses and Problems
8. Thermography Consent
9. Thermography History
10. Thermography Breast Questionnaire
11. Thermography Full Body Questionnaire
12. Anthem ABN Waiver

If have or had breast cancer, also fill:

1. Thermography Extended Breast Questionnaire
2. Thermography Detailed Extended Breast Questionnaire

Female Full Body Thermography Follow up Patients:

If you are a follow up patient please download the form below and bring it filled out to your next visit.

1. Thermography History
2. Thermography Breast Questionnaire

 

Lower Body Thermography

1. Patient Data
2. Receipt of Privacy
3. Financial Policy
4. Advanced Beneficiary Notice
5. General Adult History
6. Schedule of Medications and Supplements
7. Diagnoses and Problems
8. Thermography Consent
9. Thermography History
10. Thermography Lower Body Questionnaire
11. Anthem ABN Waiver

Lower Body Thermography Follow up Patients:

If you are a follow up patient please download the form below and bring it filled out to your next visit.

1. Thermography History

 

Region of Interest Thermography

1. Patient Data
2. Receipt of Privacy
3. Financial Policy
4. Advanced Beneficiary Notice
5. General Adult History
6. Schedule of Medications and Supplements
7. Diagnoses and Problems
8. Thermography Consent
9. Thermography History
10. Thermography Region of Interest Questionnaire
11. Anthem ABN Waiver

Region of Interest Thermography Follow up Patients:

If you are a follow up patient please download the form below and bring it filled out to your next visit.

1. Thermography History

Male Upper Body Thermography

1. Patient Data
2. Receipt of Privacy
3. Financial Policy
4. Advanced Beneficiary Notice
5. General Adult History
6. Schedule of Medications and Supplements
7. Diagnoses and Problems
8. Thermography Consent
9. Thermography History
10. Thermography Upper Body Questionnaire
11. Anthem ABN Waiver

Male Upper Body Thermography Follow up Patients:

If you are a follow up patient please download the form below and bring it filled out to your next visit.

1. Thermography History

 

Female Upper Body Thermography

1. Patient Data
2. Receipt of Privacy
3. Financial Policy
4. Advanced Beneficiary Notice
5. General Adult History
6. Schedule of Medications and Supplements
7. Diagnoses and Problems
8. Thermography Consent
9. Thermography History
10. Thermography Breast Questionnaire
11. Thermography Upper Body Questionnaire
12. Anthem ABN Waiver

If have or had breast cancer, also fill:

1. Thermography Extended Breast Questionnaire
2. Thermography Detailed Extended Breast Questionnaire

Female Upper Body Thermography Follow up Patients:

If you are a follow up patient please download the form below and bring it filled out to your next visit.

1. Thermography History
2. Thermography Breast Questionnaire