Imaging for Women, L.L.C.
Mark J. Malley, MD, DABR
630 NW Englewood Road
Kansas City, MO 64118
Phone: (816) 453-2700
Fax: (816) 453-9943
Your exam date: ____________
Your exam time: ____________
Please arrive 15 minutes early to complete insurance information. Please bring your insurance card(s) and
referral/insurance authorization if needed. If you want to save yourself time, you may download and print our information
forms from our website at www.imaging4women.com then fill them out and bring them with you at the time of your
exam.
Patient’s Name: _____________________________________________
Date of Birth: ____________________
Exam: Mark exam(s) requested
Reason for the exam: ________________________________________________
Breast Consultation
Mammogram:
Screening with CAD
Diagnostic w/US if needed
With CAD
Breast Ultrasound
Exam Preparation: No deodorant or body powder on your upper body.
*Please mark the location of any palpable masses
No preparation is needed for ultrasound of the breast.
Please call us for more information.
Rt
Lt
OB/GYN Pelvic Ultrasound
Pelvic Ultrasound
W/TV if needed
OB Ultrasound
Sonohysterography
(SHG)
Exam Preparation:
Empty your bladder one hour before the time of the exam. Following this drink 32-oz of water within 15
minutes (it takes at least 45 minutes to refill). Do not go to the bathroom again until the exam is
completed. You need a full bladder for the exam.
If you are pregnant and less than 30 weeks along, follow the above preparation. After 30 weeks of
pregnancy, you usually do not have to have a full bladder.
Take 2 Advil® or equivalent anti-inflammatory approx. 2 hours before your exam. It is best to schedule
this exam soon after your menstrual flow has completed (if possible). Please call if you have any questions.
Abdominal Ultrasound
Complete Abdomen
Gallbladder
Aorta
Kidneys
Other
Exam Preparation:
Vascular / Misc. Ultrasound
Nothing to eat after midnight.
Lower Extremity Venous
No eating 4 hrs before exam.
Right
(Sips of water to take medicine
Left
is OK.)
Both extremities
Drink 20 oz of water 1hour
Lower extremity arterial
before the exam
Carotid
Thyroid
Bone Mineralization Analysis
Exam Preparation:
None
None
None
None
Exam Preparation: Wear comfortable clothing without metal buttons,
buckles or zippers.
DEXA Scan
X-Ray/Plain Films
Exam:
CHILDREN MUST BE ACCOMPANIED
BY AN ADULT IN THE RECEPTION
AREA WHILE THE PATIENT IS HAVING
THEIR EXAM. NO CHILDREN ARE
ALLOWED BACK IN THE EXAM
ROOMS.
Exam Preparation: None
Reporting Instructions:
Fax report at completion of exam as usual.
Call report immediately.
Keep patient until my office calls with instructions.
If you have any questions or
need to reschedule your exam,
Please feel free to call us.
PHONE: 816-453-2700
Please schedule my patient for the exams listed above:
Patient contact: Home Phone: _________________
Work phone: _____________ Cell Phone: ____________
See Map on Back
Physician Signature: ____________________________________
DIRECTIONS: Imaging for Women is easy to locate. You can find us at the intersection of Highway 169 & Englewood
Road in the Englewood Plaza Shopping Center (we are across from the Bank of America). Turn into the shopping center
at the Quick Trip.
Mammography: We offer new state-of-the-art digital mammograms with CAD (Computer Aided
Diagnosis).
Bone Density Analysis: After your analysis, we counsel you on a basic program to slow or reverse
bone loss.
Ultrasound: We offer state-of-the-art GE Ultrasound equipment.
Digital Plain Film/X-rays: (Chest, Abdomen, Hands, Feet, Knees, etc.)
Total body fat composition (not covered by insurance).
At Imaging for Women, we'll take care of YOU!