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Facility addresses and services on reverse side....Medical City Dallas 7777 Forest Lane, Suite C-236...
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Facility addresses and services on reverse side. Download extra copies of this form at: SolisMammo.com/about/tools Patient Name DOB Patient Phone Number Physician Date Physician Phone Physician Fax Physician NPI PATIENT INFORMATION © Copyright 2020 Solis Mammography | NTX 2.20 Screening Mammogram. If Radiologist determines clinically necessary, proceed w/ additional views and/or Ultrasound. Screening Mammogram General Ultrasound (Central Plano Only) Diagnostic Mammogram w/ Ultrasound as indicated Diagnostic Mammogram Breast Ultrasound Breast Biopsy (Ultrasound Guided/Stereotactic) BREAST EXAMINATION REQUEST SELECT REASON FOR PROCEDURE Screening for Osteoporosis Osteopenia Other Post-Menopausal, Natural Status Osteoporosis Post-Menopausal, using HRT Long-term, current, use of Steroids or High-risk Medications BONE DENSITOMETRY REQUEST DEXA Bone Densitometry DEXA with Vertebral Fracture Assessment Right Left FOR CLINICAL USE ONLY Indicate Area of Concern Select Reason for Procedure Breast Mass Family History of Breast Cancer Breast Pain Personal History of Breast Cancer Breast Cyst Abnormal Mammogram Physician Signature Date Time LOCATION Schedule by Phone 866.717.2551 Fax Number 866.366.5798 Schedule Online SolisMammo.com 3D mammography (tomosynthesis) is available at all DFW locations. Alliance Arlington Burleson Cedar Hill Dallas (Medical City) Denton Denton South Flower Mound Fort Worth (BASH) Frisco (Main St.) Frisco (Warren Pkwy.) Garland (Firewheel) Granbury Grand Prairie HEB Las Colinas Lewisville Mansfield McKinney Mesquite Plano (Central) Plano (West) Prosper Red Oak Southlake University Park Weatherford
Transcript of Facility addresses and services on reverse side....Medical City Dallas 7777 Forest Lane, Suite C-236...
Facility addresses and services on reverse side.
Download extra copies of this form at: SolisMammo.com/about/tools
Patient Name DOB Patient Phone Number
Physician Date
Physician Phone Physician Fax Physician NPI
PATIENT INFORMATION
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Screening Mammogram. If Radiologist determines clinically necessary, proceed w/ additional views and/or Ultrasound. Screening MammogramGeneral Ultrasound (Central Plano Only)
Diagnostic Mammogram w/ Ultrasound as indicatedDiagnostic MammogramBreast UltrasoundBreast Biopsy (Ultrasound Guided/Stereotactic)
BREAST EXAMINATION REQUEST
Select Reason for ProcedureSELECT REASON FOR PROCEDURE
Screening for OsteoporosisOsteopeniaOther
Post-Menopausal, Natural StatusOsteoporosis
Post-Menopausal, using HRTLong-term, current, use of Steroids or High-risk Medications
BONE DENSITOMETRY REQUEST
DEXA Bone Densitometry DEXA with Vertebral Fracture Assessment
Reason for Exam:
Right Left
Physician Signature
3801 W. 15th Street, Suite 150APlano, TX 75075Fax: 866.366.5798
5920 W. Parker Road, Suite 200Plano, TX 75039Fax: 866.366.5798
Frisco Firewheel (SCREENING ONLY)5575 Warren Parkway, Suite 220Frisco, TX 75035Fax: 214.705.9240
4430 Lavon Drive, Suite 326Garland, TX 75040Fax: 866.366.5798
FOR CLINICAL USE ONLY
Indicate Area of Concern
Select Reason for Procedure
Breast MassFamily History of Breast Cancer
Breast PainPersonal History of Breast Cancer
Breast CystAbnormal Mammogram
Physician Signature Date Time
LOCATION
Schedule by Phone866.717.2551
Fax Number866.366.5798
Schedule OnlineSolisMammo.com
3D mammography (tomosynthesis) is available at all DFW locations.
AllianceArlingtonBurlesonCedar HillDallas (Medical City)
DentonDenton SouthFlower MoundFort Worth (BASH) Frisco (Main St.)
Frisco (Warren Pkwy.) Garland (Firewheel)GranburyGrand PrairieHEBLas Colinas
LewisvilleMansfieldMcKinneyMesquitePlano (Central)Plano (West)
ProsperRed OakSouthlakeUniversity ParkWeatherford
SolisMammo.com | P: 866.717.2551 | F: 866.366.5798
Schedule by Phone866.717.2551
Fax Number866.366.5798
Schedule OnlineSolisMammo.com
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OUR SERVICES3D MAMMOGRAPHY + SMARTCURVE™
SCREENING MAMMOGRAPHY
DIAGNOSTIC MAMMOGRAPHY
BREAST ULTRASOUND
BREAST BIOPSY
BONE DENSITOMETRY
North TexasServices and Locations
AllianceSolis Mammography, a department of Medical City Alliance3025 North Tarrant Pkwy., Suite 250Fort Worth, TX 76177Providing all servicesArlingtonSolis Mammography, a department of Medical City Arlington515 W. Mayfield, Professional Bldg. A, Suite 100Arlington, TX 76014Providing all servicesBurlesonSolis Mammography12500 South Freeway, Suite 202Burleson, TX 76028Providing all servicesCedar HillSolis Mammography617 Uptown Blvd., Suite 103Cedar Hill, TX 75104Providing all servicesDallasSolis Mammography, a department of Medical City Dallas7777 Forest Lane, Suite C-236 Dallas, TX 75230Providing all servicesDallas/University Park (NW Plaza)Solis Mammography6805 West Northwest Highway, Suite ADallas, TX 752253D screening and bone densitometry onlyDentonSolis Mammography a department of Medical City Denton3537 South I 35E, Suite 211Denton, TX 76210Providing all servicesDenton SouthSolis Mammography2817 S. Mayhill Road, Suite 270Denton, TX 76208Providing all services except bone densitometryFlower MoundSolis Mammography4001 Long Prairie, Suite 115Flower Mound, TX 75028Providing all servicesFort Worth (BASH)Solis Mammography at Baylor All Saints Hospital (Fort Worth)1250 8th Avenue, Suite 130Fort Worth, TX 76104Providing all services
Frisco (Main St.)Solis Mammography5757 Main St., Suite 102Frisco, TX 75034Providing all servicesFrisco (Warren Pkwy.)Solis Mammography5575 Warren Pkwy., Prof. Bldg. 1, Suite 220Frisco, TX 75034Providing all servicesGarland (Firewheel)Solis Mammography4430 Lavon Drive, Suite 326Garland, TX 75040Providing all servicesGranburySolis Mammography, a department of Lake Granbury Medical Center1310B Paluxy Road, Suite 1000Granbury, TX 76048Providing all servicesGrand PrairieSolis Mammography4927 Lake Ridge Pkwy., Suite 150Grand Prairie, TX 750523D screening and bone densitometry onlyHEB (Lisa Trent Breast Center)Solis MammographyLisa Trent Breast Center1615 Hospital Pkwy., Suite 108Bedford, TX 76022Providing all servicesLas ColinasSolis Mammography, a department of Medical City Las Colinas6750 North MacArthur, Suite 153Irving, TX 75039Providing all servicesLewisvilleSolis Mammography, a department of Medical City Lewisville500 West Main Street, Suite 300 Lewisville, TX 75057Providing all serviceMansfieldSolis Mammography3141 E. Broad St., Suite 331Mansfield, TX 760633D screening and bone densitometry only
McKinneySolis Mammography, a department of Medical City McKinney4201 Medical Center Drive, Suite 100AMcKinney, TX 75069Providing all servicesMesquiteSolis Mammography1515 Town East Blvd., Suite 141Mesquite, TX 751503D screening and bone densitometry onlyParisSolis Mammography 3160 Clarksville St, Paris, TX 75460Providing all servicesPlano (Central)Solis Mammography, a department of Medical City Plano3801 W. 15th Street, Bldg. C - Suite 150APlano, TX 75075Providing all services including general ultrasoundPlano (West)Solis Mammography 5920 W. Parker Road, Suite 200Plano, TX 75093Providing all servicesProsperSolis Mammography1000 N. Preston Road, Suite 30Prosper, TX 750783D screening and bone densitometry onlyRed OakSolis Mammography317 East Ovilla Road, Suite 300Red Oak, TX 751543D screening and bone densitometry onlySouthlakeSolis Mammography1545 E. Southlake Blvd., Suite 200 Southlake, TX 76092Providing all servicesWeatherfordSolis Mammography, a department of Medical City Weatherford914 Foster LaneWeatherford, TX 76086Providing all servicesWichita FallsSolis Mammography5500 Kell Blvd, Suite 110, Wichita Falls, TX 76310Providing all services
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