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Please download, print and complete the HIPAA Consent form and bring it with you on your first appointment. We have included the Pre-Thermography Scan Instructions in this document for your convenience. All of your answers to our medical questionnaire will be entered directly into the report at your appointment. If you are getting the Breast Health Study only, then please download, print and sign the Disclosure for Breast Only Thermography and bring it with you on your appointment. (No medical referral is required.)

 

Every Patient Must Complete the HIPAA Consent Form below prior to your appointment:

HIPPA Patient Authorization Form

 

If you are getting the Breast Health Study only, then please download, print and sign the Disclosure for Breast Only Thermography and bring it with you on your appointment.

Disclosure for Breast Only Thermography Form

 
PATIENT PRE-THERMOGRAPHY SCAN INSTRUCTIONS: (VERY IMPORTANT)

Unless specifically instructed by your physician, you should wait at least three months after any form of surgery (including biopsy), the completion of chemotherapy or radiation before your scan.

Avoid any natural or artificial tanning for three (3) days prior to your scan.

You must not have had significant fevers (102° or more) within thirty-six hours of your scan or have any level of fever on the day of your scan. Refrain from a sauna, steam-room or hot/cold packs for at least twenty-four (24) hours prior to your scan.

There should be no new bruising, rashes or skin irritation on the day of your scan.

With your physician’s permission, please do not use the following medications for twelve hours prior to your scan: niacin or niacin patch (500 milligrams or more), nitroglycerin or any migraine medication.

Avoid any tobacco use or caffeinated coffee or tea consumption for two (2) hours prior to your scan.

Avoid vigorous exercise, bathing or showering for one (1) hour prior to your scan.

Long hair should be worn up or pulled back off your shoulders prior to being scanned.

For Breast Imaging: Avoid any vigorous physical stimulation, examination or compression of the breasts (self or clinical examination, ultrasound or mammogram) for at least three days prior to your scan.
Do not use any skin creams, lotions, deodorants or powders that may cause inflammation on your breasts or underarms on the day of your scan. We recommend women wear a blouse and pants or skirt to your scan and please do not wear an underwire bra to the exam.

For Men: The “Men’s Health Scan” or “Full Body Scan” will require that your abdomen is revealed so it is best to wear brief underwear or a “Speedo”. You will not be required to remove your underwear.

To achieve an accurate evaluation, you should avoid conditions that would cause artificial influences. This may seem like a lengthy list of conditions to avoid however, we have determined that each of them has the potential to decrease the reliability of your scan. Please contact us if you have any questions.

June Carver Drennon * 727-729-2711
[email protected]

Please call our office at 727-729-2711 with any questions.