Auburn 253-735-1991 Federal Way 253-839-8779 PATIENT REFERRAL FORM Date_________________________ Patient__________________________________________________ DOB_________________ Phone________________________ Clinical Data________________________________________________________________________________________________ ___________________________________________________________________________________________________________ EXAMINATION REQUESTED: q Screening Mammogram (With Computer-Aided Detection and 3D Tomosynthesis) There are no patient or physician concerns. q Diagnostic Breast Evaluation to include, (if indicated) Mammography, Physical Exam, Breast Ultrasound, and Needle Biopsy. LOCATION OF CONCERN: q Breast MRI q Breast Biopsy (Stereotactic, Ultrasound-Guided, or MRI-Guided) q Bone Densitometry (DXA Scanning) RIGHTLEFT qOther________________________________________________________________________________________ PATIENT INSTRUCTIONS: No children under 12 allowed in the waiting room unless accompanied by another adult. MAMMOGRAM—Do not use talcum powder or underarm deodorant the day of your exam, as this can interfere with the detection of calcifications. Please wear a two-piece outfit. BREAST MRI—Do not use talcum powder or underarm deodorant the day of the exam, as it may result in image artifacts. Ideally, premenopausal women should have the exam 7-14 days after the start of their menstrual cycle and women on hormone replacement therapy should be off it 1-2 months prior to the exam. BREAST BIOPSY—Discontinue use of aspirin, or other mild blood thinners, five days prior to the biopsy. If you take Coumadin, Plavix, or other more potent blood thinners, you must first consult your physician to make sure it is safe to stop that medicine in advance. Please wear a two-piece outfit. BONE DENSITOMETRY—No calcium supplements 24 hours prior to exam. Wear an outfit with no metal or buttons around waist. APPOINTMENT DATE REFERRING CLINICIAN TIME PHONE EAST MAIN PROFESSIONAL 1268 East Main Street, Suite 1 Auburn, WA 98002 (253) 735-1991 Fax: (253) 735-8837 Auburn High School East Main St. Valero Station Enter 3rd St SW Cross St SE Hwy 18 PACIFIC HWY (99) SOUTH 336th 9th AVE. S 1st WAY S. OMNI BUILDING 909 S. 336th Street, Suite B101 Federal Way, WA 98003 (253) 839-8779 Fax: (253) 941-6941 I-5 TO SEATTLE EXIT 143 SOUTH 320th SOUTH 320th EXIT 142A SOUTH 348th HWY 18 Visit our website at www.breastdiagnostic.com I-5 TO TACOMA PAC IFIC HWY (99) SOUTH 348th