Bcaspa Registration Form
Cannot pre-fill email address.
Cannot pre-fill email address.
Primary Care Doctor's Name
Primary Care Doctor's Address
Primary Care Doctors Phone Number
Have you had a previous Mammogram?
Are you experiencing any breast problems at this time?
Are you pregnant?
Average household income (Per year)
Current Medical Problems.
Have you ever taken birth control?
Any family history of breast cancer?
Any family history of Ovarian cancer?
If Yes to above questions, please list family members with cancer and how long?
Do you smoke?
Age at first pregnancy?
Age at last pregnancy?
Number of children?
Age at first period?
Were all children breast fed?
Have you ever had breast cancer?
Do you have breast implants?
PLEASE READ THE FOLLOWING AND SIGN
PATIENT CONSENT/RELEASE FORM Mammography is an x-ray of the breasts.
Although mammography is the single most reliable method for detecting breast cancer
when it is early and too small to feel, a mammogram does not detect all breast cancers.
Self-breast examination and a physical exam of the breasts by a doctor are important
parts of a screening program. I understand that a clinician's breast exam may detect a
cancer that is not seen on the mammogram. Three methods, used together, have been
shown to be most effective for early detection: 1) breast self-exam, 2) mammography and
3) physical exam by a physician. Mammography as a screening exam is not appropriate
to use for women who have breast symptoms such as a lump or an abnormal discharge
from the nipple. These women need to see their physician immediately and have a
diagnostic mammogram. I am not currently pregnant, and it has been at least 3 months
since I stopped nursing a baby.
I understand if my screening mammogram is abnormal, I will require further evaluation
by a physician and, in this circumstance, I agree to take responsibility for follow-up and
to arrange for an appointment with a physician of my choice. I understand that BCASPA
Africa offers these mammography services to improve the well being of the community
by increasing the incidence of early detection of breast cancer and by increasing
awareness of the importance of early detection. I understand that some of the health
information obtained from this program may be used for educational and research
purposes and I give BCASPA by consent to do so. I understand BCASPA Africa is
offering me this service as a charitable contribution to help improve breast cancer
awareness and I hold neither BCASPA Africa nor any of its affiliates are responsible for
any damages as a result of this test. At this time, I also give my consent for BCASPA
Africa to release my mammograms and/or reports to another requesting medical facility. I also give my consent to any other medical facility to release previous mammograms,
breast ultrasounds, and/or reports and/or surgical and/or pathology reports to BCASPA
Africa including any diagnostic mammography and/or ultrasound reports. I have received
a notice of privacy practices.
Signature(Type Full Name): Date:
Technologist’s Signature: Date:
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