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Patient’s Name: ________________________________________ DOB:____________Phone: ___________________
O�ce Address/Location: __________________________________________________Phone: __________________
Referring Signature: ____________________________ ___________________ Date Ordered: _________________
Site of Previous Mammogram: ______________________________________________________________________
Screening Digital Mammogram
Bone Mineral Density DEXA (CPT 77080) - Please indicate Patient’s History:
Diagnostic Mammogram
MRI of the BreastsEvaluation of ImplantsEvaluation for Breast Cancer
2D (Standard Digital) 3D (Tomosynthesis)
2D (Standard Digital)
Screening Breast Ultrasound Dense Breasts, asymptomaticand negative mammogram.(If 40 or older)
3D (Tomosynthesis) Right
*must indicate site of concern on diagram*must indicate site of concern on diagram
Left Both
LT RT Bilateral
Personal History of Breast CancerLump - (if patient under 30 start with Breast Ultrasound - females only) Focal Point of PainSpontaneous Nipple DischargeCall Back From Screening Six Month Follow-UpOther _________________
Asymptomatic Personal History of Breast Cancer Breast Implants Other __________________
Procedures
DuctogramMRI Guided Breast BiopsyFine Needle/Cyst AspirationUltrasound Guided - Breast BiopsyStereotactically Guided Breast BiopsyNeedle Localization
Diagnostic Breast Ultrasound
Palpable LumpFocal Point of PainMass seen on MammogramOther ______________________
E x a m F i n d i n g s / S p e c i a l I n s t r u c t i o n s
IF ADDITIONAL IMAGING OR PERCUTANEOUS BIOPSY IS REQUIRED, PLEASE PROCEED WITH THESE EXAMS WHILE KEEPING ME INFORMED OF ALL RECOMMENDATIONS AND RESULTS.
MenopausalICD-10-CM
To Schedule Appointment Please Call: 714 784-1643
or Fax: 949 753-9030
Today’s Date:
_________
Hysterectomy with removal of ovaries Known Osteopenia or Osteoporosis
Fracture of any boneduring adult life
Hyperthyroidism
ONLINE APPOINTMENTS Now Available!
Access the portal at wcrc.com Use of Thyroid Medications History of Steroid Use
PATIENT LEFT PATIENT RIGHT
*must indicate site of concern on diagram
Santa Ana/Tustin: 1100-A N. Tustin Avenue, Santa Ana, CA 92705Newport Beach: 1441 Avocado Ave.,Suite 301, Newport Beach, CA 92660
Indicates Walk-in screening o�ered
***
[*]
Garden Grove: 9191 Westminster Ave, Garden Grove, CA 92844Orange: 230 S. Main Street, Suite 100, Orange, CA 92868
*Please have patient bring doctor’s order; If new patient, bring ALL prior outside mammograms & accompanying reports to appointment.* **Women with a recent breast cancer diagnosis or new breast issue are not eligible for Walk-in Screening Program**
Annual Screening Mammograms Now o�ered on a Walk-in Basis. No appointment needed if: No changes since last mammogram
Please see other side for instructions and map.
LOCATION OF CONCERN MUST BE NOTED ON REFERRAL.
PLEASE CHECK
WCRC_BREAST_COMPLETE_IRVINE_REV12192019VER1MC
[ ]Make an appointment for your next DEXA (Bone Density),Mammography, or Ultrasound exam online. Reserve a time
slot that is convenient for you. Download into your calendar.
Preparation for Digital Mammogram Examination:· No perfume, deodorant or body powder the day of the exam
· Please bring any previous mammogram �lms and reports
(if done at another facility).
· Please wear two piece clothing.
· Do not schedule one week before menstrual period.
Preparation for DEXA Exam:· Patients should not be scheduled within two weeks of any
diagnostic or CT exam utilizing
Barium, or any nuclear medicine exam.
· If possible, do not wear clothing with metal buttons or zippers.
Preparation for Breast Biopsy:· No aspirin or “blood thinner” one week prior to biopsy.
· Please consult your physician prior to discountinuing medications.
NO PREP NEEDED FOR BREAST ULTRASOUND OR CYST ASPIRATION.
BREAST IMAGING SCHEDULING GUIDELINES
Breastlink Women’s Imaging
Garden GroveDigital Mammography,
Breast Ultrasound, Breast Biopsy,DEXA
9191 Westminster Ave., Suite 210 Garden Grove, CA 92844
P:(714)784-1657F:(714) 891-6064
Breastlink Women’s Imaging
OrangeDigital Mammography,
Breast Ultrasound, Breast Biopsy,
Stereotactic Breast Biospy,Breast MRI, DEXA
230 S. Main Street, Suite 100Orange, CA 92868P:(714) 541-0101F:(714) 541-0450
Breastlink Women’s Imaging
Newport BeachMammography,
Ultrasound, Breast Biopsy
1441 Avocado Ave.,Suite 301Newport Beach, CA 92660
P:(949) 272-2095F:(949) 272-2096
Breastlink Women’s Imaging
Santa Ana/TustinDigital Mammography,
Breast Ultrasound, Breast Biopsy, Breast MRI, DEXA
1100-A North Tustin AvenueSanta Ana, CA 92705
P:(714) 543-9927 F:(714) 543-5883
WCRC_BREAST_COMPLETE_WIRVINE_REV01102019VER1MC
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LagunaBeach
Irvine
Fullerton
NewportBeach
HuntingtonBeach
DanaPoint
GardenGrove
YorbaLinda
SantaAna
LagunaHills
MissionViejoLaguna
Beach
Irvine
Fullerton
Newport
Costa Mesa
Beach
HuntingtonBeach
DanaPoint
GardenGrove
Orange
Tustin
YorbaLinda
SantaAna
LagunaHills
MissionViejo
La Mirada
5 Miles
10 Miles
ORANGECOUNTY
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