Breast Imaging Request
NAME:
DATE OF BIRTH:
Patient
ADDRESS:
TELEPHONE
IS THE PATIENT PREGNANT?
REGION
MEDICARE NO:
YES
NO
BREAST IMAGING REQUEST
RIGHT BREAST
LEFT BREAST
BILATERAL
MAMMOGRAPHY +/– ULTRASOUND
ULTRASOUND
ULTRASOUND BIOPSY
STEREOTACTIC BIOPSY
CT
NUCLEAR MEDICINE +/– X-RAY
CONTRAST ENHANCED SUBTRACTED MAMMOGRAPHY (CESM)
BREAST MRI REQUEST
MRI NON-REBATABLE (does not meet eligibility criteria)
1. High Risk Br Ca mutation on genetic testing
2. On same side of family
a. 1st or 2nd degree relative with Breast Ca <45 years and another 1st or 2nd degree relative with bone or soft tissue sarcoma <45 years.
b. Three or more 1st or 2nd degree relatives with breast or ovarian Ca.
3. On same side of family, two 1st or 2nd degree relatives with breast or ovarian Ca and one relative with one of the following:
a. Bilateral breast Ca
c. Onset Ovarian Ca before age 50
e. Breast Ca in a male relative
b. Onset Breast Ca before age 40
d. Breast and ovarian Ca in one relative f. Ashkenazi Jewish ancestry
MRI BREAST BIOPSY REQUEST
Examination Required
MRI SCREENING (eligibility criteria for Medicare rebate below, tick one)
Asymptomatic female under 50 with:
BREAST MRI BIOPSY
MRI
+/– ORBITS +/– SKULL +/– CHEST X-RAY IMPORTANT: Indicate whether the following applies to your patient
History of welding, grinding, sheet metal work Brain aneurysm clip
YES
YES
NO NO Cardiac pacemaker
Cochlear implant
YES
YES
NO
NO
DATE LMP:
FHx BREAST Ca
LEFT
YES
NO
HRT
YES
NO
OCP
YES
NO
POST MENOPAUSAL
YES
NO
SURGERY
YES
NO
DETAILS:
)
FILMS AND REPORTS WITH PATIENT
FACSIMILIE REPORT (NO.
)
MIA DIRECT
PROVIDER NO:
REFERRER ADDRESS: COPY REPORT TO:
Referring
Doctor
REFERRER NAME:
SIGNATURE:DATE:
PLEASE BRING PREVIOUS
FILMS FOR COMPARISON
Your doctor has recommended that you use MIA Radiology. You may choose another provider but please discuss this with your doctor first.
Results
TELEPHONE REPORT (NO.
Clinical Notes
RIGHT
CURRENTLY BREASTFEEDING
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