Please click on the link(s) below to download forms for your appointment.  It will save time and help you fill out the forms more accurately if you can complete this before your appointment.

Please call 239.307.5616 with questions.

FORMS FOR THERMOGRAPHY:

ALL PATIENTS:

Please download and read How to Prepare for Your Thermogram prior to your thermography appointment!  It is important that you do not schedule thermography immediately following therapy such as massage, acupuncture, chiropractic, etc.  Also plan to not workout or have prolonged exposure to sunlight or heat prior to your scan. Or you can visit our webpage to read these important INSTRUCTIONS on How to Prepare for Your Thermogram

INTAKE FORMS TO DOWNLOAD:

Patient Info Questionaire (all patients: please download & fill out)
Breast Questionnaire history form (Required for Breast Scan)
Full Body Questionnaire form – download if needed
Upper Body Questionnaire form – download if needed

PHYSICIAN/CLINICIAN REFERRAL FORMS:

Doctor Requisition Form for Breast Scan
Doctor Requisition Form for Pain Evaluation