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Coastal Thermal Imaging

Coastal Thermal Imaging

Medical Thermography

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Forms

We Believe

Overview of Services

24 Hours Prior to Appointment Instructions

Breast Questionnaire

Screening Breast Thermography Patient Disclosure

HIPAA Patient Authorization Form

Women’s Health Screening with Abdomen Form

Women’s Comprehensive Full Body Screening Form

Men’s Health Screening Form

Men’s Comprehensive Full Body Screening Form

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Is Thermography Right for Me?

ο Heart Disease runs in my family.
ο I have TMJ or my jaw clicks.
ο I have had extensive dental work.
ο I have a digestive disorder or painful digestion.
ο I have fatigue, weakness or unexplained pain.
ο I have a low-functioning thyroid.

Breast disease risk factors:
ο I have fibrocystic breasts.
ο I have smoked for more than 5 years.
ο I have used pharmaceutical hormone replacement therapy or birth control.
ο I have tender breasts, lumps, nipple discharge, change in breast size.
ο I am concerned about radiation exposure.
ο I have a family history of breast disease.
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