For All Thermograms READ / Complete The Following
Pre-Thermogram Exam Instructions
Please follow these instructions. Not doing so may
interfere with a clinically useful thermogram.
Electronic
Transmission HIPPA Compliance This form is only
necessary if your thermogram is being sent to Dr. Cockburn for
evaluation. All breast thermograms will require this form.
Other thermograms may be read in house, thereby making this form
unnecessary, but we ask that you complete this form unless you
have been advised it is not necessary.
Thermogram Specific Forms. Complete
THE Appropriate Form(s)
Breast - Release For Testing
Breast
Thermography Pre Exam Form
Pain /
Neurovascular / Full Body Pre Exam Form
New Patient Forms
New Patient Registration Form
HIPPA
New Patient
Information Sheet
Other Information
Physician Breast Thermography Information
Thermographically identified breast cancer (Images) Cancer
is in the left breast. The images on the left are
pretreatment and on the right are following treatment.
