Prior Imaging Request Form
Please complete the form below so our Care Team can request your prior breast imaging on your behalf.
ROI Forms
First Name
Middle Name
Last Name
Please enter your email address for identification purposes
Phone Number
Please enter your date of birth
Will you be using our physician partner, Karis Healthcare?
Yes
No
Please enter the date of your last imaging
Please enter the name of facility that performed your previous imaging session
Facility Address
Facility Phone Number
Facility FAX Number
Medical Record Number (If available)
Please release my mammography studies in a DICOM format via CD or films to (Powershare is the preferred method): CD or Film Gnosis for Her 300 Spectrum Center Dr Suite 200 Irvine, CA 92618 Phone: 888-311-5220 Powershare Innovative TeleRadiology, Inc. Fax: (404) 745-8744 Phone: (866) 487-7231 AMBRA Email:
[email protected]
&
[email protected]
Consent is provided in the signed section below.
Yes
I hereby consent and authorize you to release copies of my medical records related to all breast procedures, including current and previous records from other practices, practitioners, hospitals, imaging centers, and/or clinics that are part of my medical history. This may include information concerning cancer, cancer testing, and cancer results. This authorization permits release of digital images (lossless format), radiology reports, breast density notifications, and any related documentation. A copy or fax of this release shall be considered as valid as the original.
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