D.O.B. · Information Regarding Your Mammogram Thank you for choosing Advocate Condell Medical...
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24-0902 2/17 WOMAN’S IMAGING PHYSICIAN ORDER Libertyville, IL 60048 Patient Name: ________________________________________________________ D.O.B. _____________________________________ Patient Phone #: __________________________________ MR#: ________________________________________________ Patient Diagnosis: _______________________________________________________________________________________ Patient diagnoses are required for billing. DO NOT use “rule out” or “suspected”. Use signs, symptoms, patient complaints, and known diagnoses. Use a narrative diagnosis rather than an ICD code. M Screening Mammogram (No problems) M Left M Right M Bilateral Screening Mammography Indications: Asymptomatic/Routine or history of breast cancer greater than 2 years M Tomosynthesis /3D (No problems) M Left M Right M Bilateral M Screening Breast Ultrasound (No problems) M Left M Right M Bilateral Screening Breast Ultrasound Indications: Available only after mammographic diagnosis of dense breast tissue. M Diagnostic Mammogram M Left M Right M Bilateral M Add Ultrasound if indicated M Tomosynthesis Diagnostic Mammography Indications: Work up for a prior abnormal mammogram within 1 year, a history of breast cancer less than 2 years, and patients with acute symptoms – lump, nipple discharge, focal pain, etc. M Diagnostic Ultrasound M Left M Right M Bilateral Diagnostic Ultrasound Indications: Evaluation of an area of clinical concern or abnormal mammographic findings. M Breast MRI Bilateral with and without Contrast M Core Biopsy M Left M Right M Stereotactic M Ultrasound M MRI M Ductogram M Left M Right M Cyst Aspiration M Left M Right M Dexa Scan M Wireless Localization M Left M Right Physician Name: ________________________________________ Signature: _________________________________ Date: _________________________ Copies To: __________________________________________________________ Thank you for choosing Advocate Condell Medical Center Right Left To make an Appointment: Please Call 847.990.6000 Fax Order 847.573.4300 Email Order [email protected] Please Indicate Location of Concern:
Transcript of D.O.B. · Information Regarding Your Mammogram Thank you for choosing Advocate Condell Medical...
24-0902 2/17
WOMAN’S IMAGING PHYSICIAN ORDER
Libertyville, IL 60048
Patient Name: ________________________________________________________
D.O.B. _____________________________________
Patient Phone #: __________________________________ MR#: ________________________________________________
Patient Diagnosis: _______________________________________________________________________________________
Patient diagnoses are required for billing. DO NOT use “rule out” or “suspected”. Use signs, symptoms, patient complaints, and known diagnoses. Use a narrative diagnosis rather than an ICD code.
M Screening Mammogram (No problems) M Left M Right M Bilateral
Screening Mammography Indications: Asymptomatic/Routine or history of breast cancer greater than 2 years
M Tomosynthesis /3D (No problems) M Left M Right M Bilateral
M Screening Breast Ultrasound (No problems) M Left M Right M Bilateral
Screening Breast Ultrasound Indications: Available only after mammographic diagnosis of dense breast tissue.
M Diagnostic Mammogram M Left M Right M Bilateral M Add Ultrasound if indicated M Tomosynthesis
Diagnostic Mammography Indications: Work up for a prior abnormal mammogram within 1 year, a history of breast cancer less than 2 years, and patients with acute symptoms – lump, nipple discharge, focal pain, etc.
M Diagnostic Ultrasound M Left M Right M Bilateral Diagnostic Ultrasound Indications: Evaluation of an area of clinical concern or abnormal mammographic findings.
M Breast MRI Bilateral with and without Contrast
M Core Biopsy M Left M Right M Stereotactic M Ultrasound M MRI
M Ductogram M Left M Right M Cyst Aspiration M Left M Right
M Dexa Scan M Wireless Localization M Left M Right
Physician Name: ________________________________________ Signature: _________________________________
Date: _________________________ Copies To: __________________________________________________________Thank you for choosing Advocate Condell Medical Center
Right Left
To make an Appointment: Please Call 847.990.6000Fax Order 847.573.4300 Email Order [email protected]
Please Indicate Location of Concern:
Information Regarding Your Mammogram Thank you for choosing Advocate Condell Medical Center for your mammogram. Advocate Condell Medical Center is dedicated to excellent quality and service. All radiologists are board certified and are committed to provide timely accurate results to our customers.
For your convenience we offer three locations for your Screening Mammograms:
Advocate Condell Medical Center
801 S. Milwaukee Ave. Libertyville, IL 60048
Advocate Grayslake Mammography Center 1170 E. Belvidere Rd.
Suite 107 Grayslake, IL 60030
Advocate Condell Outpatient Imaging
1435 N. Hunt Club Road Gurnee, IL 60031
Previous Films:
Previous films aid the radiologist with their interpretation of your exam and reduce call back rates. If you have had a mammogram at another facility, please contact that facility to have your prior films released to Advocate Condell Medical Center. The films must be received at least 30 minutes prior to your appointment for Diagnostic Mammograms.
Please have films mailed to:
Advocate Condell Medical Center 801 S Milwaukee Ave ATTN: Women’s Center/Mammography Libertyville, IL 60048
Please call 847.990.5250 if you have questions or concerns regarding the transfer of your previous films.
On the day of your test:
• Please do not wear deodorant or perfume. Condell will provide deodorant to apply following your test.• We recommend you wear a two-piece outfit as you will only need to undress from the waist up for your
mammogram.• Please arrive 15 minutes prior to your schedule time to allow for check-in. Unless you are bringing
films, as films must be received at least 30 minutes prior to your appointment for DiagnosticMammograms.
• You will be provided a gown for comfort during your exam.• Expect to spend up to 30 minutes at the center for a screening mammogram or up to 2 hours for
Diagnostic mammography and additional views.
Results:
• Your physician will receive your results within 1-2 business days.• You may be asked to return for additional imaging. Please do not be alarmed. Twelve percent (12%)
of all mammography patients are asked to return for additional imaging to complete their exam.• If you are asked to return, you will need to obtain an order from your physician and call 847.990.6000
to schedule your appointment.• To obtain your films or reports, please contact Advocate Condell Medical Center at 847.990.5250.
Advocate Condell Medical Center801 S. Milwaukee Ave.Libertyville, IL 60048
Advocate Condell Outpatient Imaging1435 N. Hunt Club Road
Gurnee, IL 60031
For your convenience we offer two locations for your Screening Mammograms:
