Complete a referral form and schedule a mammogram appointment for the patient below. Scenario: Georgia Thompson needs to have her first mammogram appointment scheduled for her. She has transportation...

Extracted text: Complete a referral form and schedule a mammogram appointment for the patient below. Scenario: Georgia Thompson needs to have her first mammogram appointment scheduled for her. She has transportation arrangements for Tuesdays and Thursday from 9:00am – 1:00pm. Her diagnosis is right breast – Cyst of breast and unspecified breast disorder – calcification. Georgia's last menstrual period was 05/27/XX. Copies of her mammogram need to be sent to Dr. Smith at 2121 College Drive, Suite 450, Middleton California, 55456. (916) 555-4321. - Patient Demographics: DOB: 05/28/1955 Name: Georgia Thompson Insurance: Cigna Phone # (209) 555-1234 ID #: U26183656 02 CPT: 77055 ICD10: N60.01, R921 Authorization #: 135674


Extracted text: fraserhealth BREAST HEALTH CLINIC REFERRAL JIM PATTISON OUTPATIENT CARE AND SURGERY CENTRE MSXX104484A Rev: Feb. 11/11 Fax Completed Referral Forms to 604-582-3787 Page: 1 of 1 Phone: 604-582-4563 ** INCOMPLETE DOCUMENTS WILL BE RETURNED** Patient's FullI Legal Name: Thompson Georgia Date of Birth: OS/28/1955 Last Personal Health Number: First Midde Gender: Female Home Phone No. a16)555-4321 Okay to Call Message Phone No. Insurance Type Interpreter Required: Examination Requested Mammography No Yes Language: FOR CLINIC USE ONLY Breast Ultrasound Rt Lt Bilateral I understand and agree that referral to the Breast Health Clinic includes Medical Imaging, a clinical examination (breast surgeon) and a core biopsy if indicated Proceed to further imaging if indicated (Mammography/Ultrasound/MRI) Arrange biopsy if indicated Present Complaint: (see back for referral criteria) Please Mark Area(s) of Concern: Lump Thickening Nipple discharge/inversion/skin changes Localized pain/tenderness Dimpling, contour deformity Previous breast cancer (new symptoms) Abnormal Screening Mammogram Re-referral to Breast Health Clinic Right Left Bilateral Follow up of previous findings Specify: Other: History: Menopause / LMP: Previous Mammograms: Yes No Location: Date: Hormone Therapy: Yes No Location: Date: Previous Ultrasound: Yes No Family History of Breast Cancer Yes No Location: Date: Relationship Age Location: Date: Previous Biopsies/Surgeries: Previous Images/reports requested Date: **Clinic appointment will not be booked until all previous breast imaging/reports received Famly Physician (If different from referring source) Referring Health Care Provider: Name: Name: MSP #: MSP #: Phone: Fax: Phone: Fax: GP Specialist NP Hospitalist ER Other Patient has no GP/NP Referring Physiclan Signature: Printshop # 261984