MAMMOGRAPHY FILM TRACKING FORM

Date of Exam:
*

Patient Name:
*

Patient Email:
*

Date of Birth:
*

Phone # Where Patient Can Be Reached:
*

Patient States Films Can be Located At:

Address:

Phone:
*

2.)
Facility Name:

Address:

Phone:

PLEASE SEND FILMS & REPORTS

I, * understand that finding my prior mammography film(s) and having
them delivered to Millennium Physician Group Imaging is necessary so the Radiologist can obtain prior history
and identification(s) on the film(s) to make an informative interpretation of my current image(s).
Please be advised that Millennium Physician Group Imaging can only wait a maximum of seventy-two hours for
your prior film(s) to arrive before the radiologist will have to interpret the current film(s).
By signing this form, I am stating that I have read and understand the above, that my film(s) have not yet been
located and that I have given you all the information as to where to obtain these film(s). I will also try to obtain
these film(s) and either bring them with me to my appointment, or have them sent to Millennium Physician Group
Imaging before the seventy-two (72) hour cut off point.

PATIENT ‘S SIGNATURE (Type name) *