This patient intake form MUST be completed 24 hours prior to your scheduled exam, failure to do so results in a $50 charge and cancellation of your appointment.

This form is NOT set up for mobile completion, please complete on a computer.

If you have any questions regarding this form, or if your appointment is less than 24 hours away please contact us for further assistance. 

Mandatory Protocols for Thermal Imaging


Patient Preparation:

Thermal imaging is a heat sensitive test. Anything which creates heat should be avoided prior to testing. Excessive metabolic activity, friction, or any of the activities listed below which will alter heat readings.


1 Month Prior:

  • No minor breast surgery, i.e. biopsy

  • We may still perform testing after biopsy. Write this in form.

1 Week Prior:

  • Be cautious of too much sun exposure in order to avoid sunburn. Scans will have to be rescheduled if the patient has a sunburn of any sort.


48 Hours Prior:

  • Men with beards should shave their face and neck, as well as backs

  • Avoid all tanning and limit sun exposure


24 Hours Prior:

  • Avoid chiropractic care, massage therapy or acupuncture

  • No saunas, steam baths, hot tubs, heating pads, or hot water bottles

  • No analgesic creams or balms

  • Do not shave underarms (Should be done day prior)

  • Reschedule if you experience a significant fever (100 degrees or more)

  • Refrain from sexual activity


Day of Exam:

  • Do not use creams, lotions, cosmetics, ointments, deodorant, antiperspirants, powders or any other skin product

  • Please bring a hair tie and headband to remove hair from your forehead and back of neck

  • Remove all piercings and jewelry prior to exam, unless unable to.


4 Hours Prior:

  • Avoid hot showers or shaving

  • Avoid physical therapy or exercise

  • No coffee, tea, soda, or other beverages containing caffeine. No alcoholic beverages.

  • Do not smoke cigarettes or use any product which contains nicotine

  • Women- do not wear a bra for the 4 hours leading up to the exam


2 Hours Before the Exam:

  • Avoid hot or cold liquids

  • Avoid eating or chewing gum

  • Avoid using a cell phone

  • Avoid heated seats

  • Do Not wear face coverings or masks


Prior to and During Exam:

  • Please inform us if you have a hot flash during the session

  • Try to relax prior to and during the exam. Stress will affect your exam.  

  • Do not wear face coverings or masks