
InfraMed Thermography
See MORE with thermography
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:
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No minor breast surgery, i.e. biopsy
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We may still perform testing after biopsy. Write this in form.
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1 Week Prior:
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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:
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Men with beards should shave their face and neck, as well as backs
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Avoid all tanning and limit sun exposure
24 Hours Prior:
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Avoid chiropractic care, massage therapy or acupuncture
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No saunas, steam baths, hot tubs, heating pads, or hot water bottles
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No analgesic creams or balms
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Do not shave underarms (Should be done day prior)
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Reschedule if you experience a significant fever (100 degrees or more)
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Refrain from sexual activity
Day of Exam:
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Do not use creams, lotions, cosmetics, ointments, deodorant, antiperspirants, powders or any other skin product
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Please bring a hair tie and headband to remove hair from your forehead and back of neck
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Remove all piercings and jewelry prior to exam, unless unable to.
4 Hours Prior:
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Avoid hot showers or shaving
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Avoid physical therapy or exercise
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No coffee, tea, soda, or other beverages containing caffeine. No alcoholic beverages.
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Do not smoke cigarettes or use any product which contains nicotine
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Women- do not wear a bra for the 4 hours leading up to the exam
2 Hours Before the Exam:
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Avoid hot or cold liquids
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Avoid eating or chewing gum
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Avoid using a cell phone
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Avoid heated seats
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Do Not wear face coverings or masks
Prior to and During Exam:
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Please inform us if you have a hot flash during the session
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Try to relax prior to and during the exam. Stress will affect your exam.
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Do not wear face coverings or masks