Medical Thermal Imaging Consent
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1 Medical Thermal Imaging Consent Patient s Name: Age: Date: Address: City: State: Zip: Home Phone: Cell Phone: Referred By: Check here to have your report and history forms sent to your doctor at Integrative Medical Specialists. Please Send a Copy to (Please include City and State): 1) 2) Instructions: Please read the following carefully. If you are in agreement with this consent form, sign and date it at the bottom. Please feel free to ask questions if there is anything that you do not understand on this form. Thermography is a procedure utilizing digital infrared imaging cameras to visualize and obtain an image of the infrared heat coming off the surface of the skin. The thermographic procedure is performed in order to analyze temperature patterns on the body that may or may not indicate the presence of a disease process. Consequently, a normal thermogram does not rule out the presence of significant pathology. Thermography is used along with X-ray, CT, MRI, mammography, ultrasounds and other imaging procedures and is not a stand-alone examination tool. Like other imaging tests it is an adjunctive tool, which while reliable should be utilized by the patient s treating physician along with other tests and analyses to arrive at a provisional or more complete diagnosis. No surgical procedure should be based on thermal imaging alone. Additional examination procedures, which depend on the nature of the condition and/or body region, are needed to achieve a final diagnosis. Thermography must not be confused with EBT or CT full body scanning. EBT and CT body scanning are structural imaging technologies, which look for the physical existence of tumors and other body structure changes while thermography does not. This office provides only the thermographic component of a complete evaluation. I understand that I will be disrobed (from the waist up for breast exams, and buttocks exposed for lower body exams) during part of the examination for both imaging and to allow for the surface temperature of my body to acclimate with the room. I have also been informed in advance that a female technician will be in the room to operate the thermal imaging camera. My body will be imaged with a digital infrared camera. I understand that this procedure does not use radiation. It is not harmful to me. Its sole function is to produce an image of the heat coming off my body. I also understand that a brief physical examination of any suspect areas found on the thermographic images may be performed in order to fully characterize the findings. The information provided will be made available to your doctor upon request for further work-up should an abnormality be detected. I have been informed about pre-examination preparation to insure the most accurate thermographic examination possible, and have complied with this protocol. Having understood the above, and having received satisfactory answers to any and all questions that I may have had concerning the purpose and outcome, risk factors and benefits of a thermographic examination, as well as the utilization of the procedure, I hereby consent to both initial and subsequent thermographic examinations. I also understand that thermography is not a substitute for mammography, ultrasounds, CT, MRI or any other form of imaging. Patient s (Guardian s) Name: (Please Print) Date: Patient s (Guardian s) Signature: Date: 5/9/2014 Form TH W. Valley Parkway Suite 204 Olathe, KS Phone (913) Fax (913)
2 Thermal Imaging Instructions Name DOB Body Temperature Room Temperature Technician Welcome to Midwest Thermography. Before you arrive for your thermographic examination, certain protocols must be followed in order to ensure that your images reflect accurate information. Please check each box confirming the following instructions have been followed. Please bring a list medications you are currently taking as well as any prior examination reports that describe breast findings you are concerned about. No recent sunburn or skin burn of any kind. Any laser treatments to the areas being imaged must be done 5 days prior to the exam. Allow 4-6 weeks after biopsy before imaging and allow 3 months post radiation. No Vitamin C IV drips, sauna or hot tub 24 hours prior to the thermal imaging. No use of deodorants, lotions, oils, creams (including hormone creams), powders, perfume, body sprays or makeup on the areas being imaged. No shaving of the areas to be imaged for at least 6 hours prior to the exam. No treatment (chiropractic, acupuncture, massage, TENS, physical therapy, electrical muscle stimulation, ultrasound, hot or cold pack use) or any physical stimulation of the areas to be imaged for 24 hours prior to the exam. No exercise 4 hours prior to the exam. No smoking for 2 hours prior to the exam. No bathing or showering for 1 hours prior to the exam. If you are nursing, avoid nursing 1 hour prior to the exam. For menstruating women, imaging must be done at least 3 days before or 3 days after menstruation. For head and neck imaging, do not floss, brush your teeth, chew gum or drink hot liquids 1 hours prior to the exam. Please note: During the examination you will be disrobed (from the waist up for breast exams, and buttocks exposed for lower body exams.) Shoes and socks will also be removed for every scan. If you are very cold sensitive bring or wear warm coverings for the areas not being imaged. The imaging room temperature is around 68 degrees F (21 degrees C.) You will acclimate in the room for 15 minutes prior to the test. A female technician is provided for all our female patients. By signing below, I certify that I have adhered to all of the above instructions, and I understand that if I have not, it can render inaccurate test results with no fault to the technician or Midwest Thermography. Signature: Date: 9/30/2014 Form TH W. Valley Parkway Suite 204 Olathe, KS Phone (913) Fax (913)
3 Cranial History Name: Sex: Age: Date: Address: City: State: Zip: Phone #: Referred by: How did you hear about us? Internet Person Other Please mark the region of your concern on the diagrams below. Please describe any specific concerns: Dental Sinuses Facial Pain or Numbing
4 Thyroid Concerns Lumps in Neck Dizziness or Lightheadedness Other Do you have any history of: Stroke Cardiovascular Disease Dizziness Fainting Past Injuries to the face Do you have any diagnosed diseases? Do you have any past surgeries to the head, face or mouth?
5 ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES This document is to be signed by a person legally responsible for the patient s medical decisions relative to the treatment situation. I,, hereby acknowledge that Midwest Thermography, (MWT) has provided me with a copy of its Notice of Privacy Practices that describes how medical information about me may be used and disclosed, and how I can access this information. I understand that if I have questions or complaints I may contact MWT at I also understand that I am entitled to receive updates upon request if MWT amends or changes its Notice of Privacy Practices in a material way. I choose to designate the individuals listed below as my primary contacts. MWT personnel may share information with these primary contacts that is consistent with the Notice of Privacy Practices. Patient s Name Contact Name Relationship Phone Signature (Patient, Parent, Authorized Signature) Patient s DOB Contact Name Relationship Phone Date FOR OFFICE USE ONLY I made a good faith effort to obtain a written acknowledgment of receipt of the Notice of Privacy Practices from the above-named patient, but was unable to because: [ ] Patient declined to sign this Written Acknowledgment. [ ] Other (specify): Signature and Title Date This section is to be completed by MWT if unable to obtain written acknowledgement from patient W. Valley Pkwy Suite 204 Olathe, KS Phone (913) Fax (913)
Medical Thermal Imaging Consent
Medical Thermal Imaging Consent Patient s Name: Age: Date: Address: City: State: Zip: Home Phone: Cell Phone: E-Mail: Referred By: Check here to have your report and history forms sent to your doctor at
Medical Thermal Imaging Consent
Medical Thermal Imaging Consent Patient s Name: Age: Date: Address: City: State: Zip: Home Phone: Cell Phone: E-Mail: Referred By: Check here to have your report and history forms sent to your doctor at
Medical Thermal Imaging Consent
Medical Thermal Imaging Consent Patient s Name: Age: Date: Address: City: State: Zip: Home Phone: Cell Phone: E-Mail: Referred By: Check here to have your report and history forms sent to your doctor at
Thermal Imaging Instructions
Thermal Imaging Instructions Name DOB Body Temperature Room Temperature Technician Welcome to Midwest Thermography. Before you arrive for your thermographic examination, certain protocols must be followed
Thermal Imaging Instructions
Thermal Imaging Instructions Name DOB Body Temperature Room Temperature Technician Welcome to Midwest Thermography. Before you arrive for your thermographic examination, certain protocols must be followed
Welcome to our Center,
Welcome to our Center, Before you arrive for your thermogram, certain protocols must be followed in order to ensure that your images reflect accurate information. Please read the following instructions
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PATIENT ENTRANCE FORM
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