Forms

 

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Please print and complete all of these forms prior to your appointment. Please do not email them back. It is very important that you read and adhere to the Patient Preparation Instructions so you can schedule your appointment appropriately and ensure accurate imaging results.

Patient Preparation Instructions

Choose either Breast or Full Body. If you are having both series, please complete both forms.

*** Disclaimer:  Thermal imaging is not a replacement for any other form of testing, but should be used in addition to other tests.This technology is not designed to see into the cavities of the body. Its strength and usefulness is to assess the surface temperature of the body, which can help a patient’s doctor to discover physical conditions. For that reason it is a tool for analysis and risk assessment.

Patient Preparation Instructions

The following instructions must be strictly adhered to before you arrive for your appointment:

  • No prolonged sun exposure (especially sunburn) to the breasts 5 days prior
    to your exam.
  • No use of lotions, creams, powders, or makeup on the breasts the day of the exam.
  • No shaving or other hair removal of the areas to be imaged the day of the exam.
  • No use of deodorants or antiperspirants the day of your exam. 
  • Do not use heated car seats within 1 hour of your exam.
  • No treatment (chiropractic, acupuncture, TENS, physical therapy, electrical muscle stimulation, ultrasound, hot or cold pack use) for 24 hours before the exam.
  • No physical stimulation of the breasts for 24 hours prior to the exam.
  • No exercise 4 hours prior to your exam.
  • If bathing, it must be no closer than 1 hour before the exam.
  • You must wait at least 4 weeks after having a fine needle or core biopsy of the breast before a thermogram can be performed.
  • You must wait at least 8 weeks after having a lumpectomy or surgical biopsy of the breast before a thermogram can be performed.
  • If you have had any medical procedure within the last 12 weeks, please notify our office before coming in for your appointment.
  • If you are nursing, please try to nurse as far from 1 hour before the exam as possible.
  • If you are using pain medications, please avoid taking them for 4 hours prior to the examination. However, you must consult with the prescribing physician for his or her consent prior to any change in medication use such as this.

Please note: During the breast procedure you will be disrobed from the waist up for both imaging and to allow the body to acclimate to the temperature of the room. For full body procedure you will be given a gown.

Surgical procedures such as implants, reductions, and biopsies do not interfere with infrared imaging. Breast thermography is perfectly safe to have during pregnancy or when nursing. The procedure may also be preformed during any part of the menstrual cycle without effecting the interpretation of the images.

If you have any further questions, please feel free to contact Advanced Thermal Imaging at (616)724-6368.

To make sure you receive your birthday gift of $50 off thermogram.