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Women’s Health Center in Lafayette3595 Mt. Diablo Blvd., Suite 350, Lafayette, CA 94549

(925) 962-9129 Ph.(925) 962-9672 Fax

(Reverse side has map, directions and preparation instructions)

Request for Mammography Examination

Patient Name:

Patient DOB:

Patient Ph#1:

Patient Ph#2:

Ordering Clinician:

Clinician Ph#1:

Clinician Ph#2:

Clinician Address:

Clinician Signature (required): Date (required):

Screening MammogramFor asymptomatic women with normal breast examwith no dominant, developing lumps or clinically concerning symptoms.

Screening Mammography(V76.10, V76.11, V76.12)

Family history of breast cancer (V16.3M, V10.3)

Previous breast cancer (V10.3)

Personal history of breast disease (V15.89)

Implants (V50.1)

Breast Reduction (V50.1)

Preferred Professional Services Group

Affiliates in Imaging:Linda Gordon, MD, Ira Kanter, MD, Less Chafen, MD, John Bokelman, MD, Yuriria Lobato, MD, Charles Fiske, MD

Bay Imaging Consultants:R. James Brenner, MD, Jimmy Cardoza, MD, Molly Honegger, MD, Phillip Wong, MD, Ying Fung, MD

No preference

#1439-BP-082913

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Welcome to the Alta Bates Summit Women’s Health Center in Lafayette

Preparation for the Exam:

Your clinician has requested the examination noted on the reverse side. Proper preparation for your exam can be critical to your care. Please read and follow the instructions below to ensure the best results.

Your mammogram should be scheduled after your period if you are still menstruating.After bathing on day of exam, please do not use powder, cream, antiperspirant or deodorant under your arms or around the breast area.Please dress in a two-piece outfit. You will be asked to remove only the top piece.Bring your prior mammogram films and reports if you are new to our center.During the mammogram, your breast is compressed between two pieces of plastic while a low-dose x-ray is taken. It is a simple procedure which takes just 10 minutes.Results are mailed to you and to your clinician within 10 business days. Some insurance programs do not reimburse for yearly screening mammograms. Please verify your insurance coverage.

NOTE: For safety reasons, children can not be present in the exam rooms. If your children accompany you to yourappointment, please have an adult to care for them during your exam.

We look forward to your visit. If you have further questions regarding your examination, please call our office at (925) 962-9129.

Check out our video tour at altabatessummit.org/lafayette/vtour.html

Women’s Health Center in Lafayette3595 Mt. Diablo Blvd., Suite 350, Lafayette, CA 94549

(925) 962-9129 Ph.

The center is located in the Mercantile Building(3595 Mt. Diablo Blvd., Suite 350), on the third floor, in the rear of the building.

The building is locatedbetween Lafayette Circle and Dewing Ave. Parking is available behind the building and is accessed from Dewing Ave. Parking is also available in the surrounding neighborhood.Come to the elevator in the back of the building just offthe parking lot and take theelevator to the 3rd floor.

Alta Bates Summitalso offers mammographyservices at these locations:

Carol Ann Read Breast Health Center3100 Summit Street, Oakland(510) 869-8377

Imaging and Mammography Center5730 Telegraph Avenue, Oakland(510) 204-1880