Patient Forms for Eldorado Hills Thermography

Which Forms You'll Need

New Client Intake Form

This form collects your contact details, date of birth, emergency contact and the name of your healthcare provider, so your report can be forwarded whenever you request it.

Health History Questionnaire

You'll answer questions about your own and your family's breast health, prior surgeries or biopsies, implants, hormone use, pregnancy or nursing status, and any current symptoms. These details give the interpreting physician valuable context.

Informed Consent

This document outlines what thermography can and cannot do, confirms that it serves as an adjunctive screening tool, and authorizes us to send your images for physician interpretation.

Pre-Appointment Checklist

A quick recap of the preparation steps listed on our Thermography Procedure page, so you arrive ready for imaging.

How to Receive Your Forms

After you book your appointment, we'll email the forms so you can fill them out at home. You're also welcome to request them at any time by emailing [email protected] or calling 916-778-7779. Bring your completed forms to your visit, or come 15 minutes early and finish them in our office.

Your Privacy

Your health information stays confidential and is used solely to perform and interpret your study. Reports are shared only with you or with the providers you authorize.