• Confidential Questionnaire for Women's Health Check

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  • Please mark YES or NO as it applies to you:

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  • Mark Right Breast or Left Breast as it applies:

  • PATIENT DISCLOSURE:

    I understand that the Report generated from my images is intended for use by trained healthcare providers to assist in evaluation, diagnosis and treatment. I further understand that the Report is not intended to be used by individuals for self-evaluation or self-diagnosis. I understand that the Report will not tell me whether I have any illness, disease, or other condition but will be an analysis of the images with respect only to the thermographic findings discussed in the Report. By signing below, I certify that I have read and understand the statements above and consent to the examination.

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  • Should be Empty: