Eldorado Hills Thermography Patient Forms

Forms Required by Eldorado Hills Thermography

New Client Intake Form

Your contact information, date of birth, emergency contact and the name of your healthcare provider, so your report can be shared at your request.

Health History Questionnaire

Questions about personal and family breast health, past surgeries or biopsies, implants, hormone use, pregnancy or nursing status and current symptoms. This information gives the interpreting physician important context.

Informed Consent

Explains what thermography can and cannot do, confirms that it is an adjunctive screening tool and authorizes us to send your images for physician interpretation.

Pre-Appointment Checklist

A summary of the preparation steps on our Thermography Procedure page so you arrive ready for imaging.

How to Get Your Eldorado Hills Thermography Forms

Once your appointment is booked, we will email your forms so you can complete them at home. You can also request them anytime at [email protected] or by calling 916-778-7779. Please bring the completed forms with you, or arrive 15 minutes early to fill them out in our office.

Eldorado Hills Thermography Privacy

Your health information is kept confidential and is used only to perform and interpret your study. Reports are released only to you or to the providers you authorize.