MMO - Vital Imaging

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MMO

Demographics

WHEN YOU START THE DEMOGRAPHIC PLEASE INCLUDE THESE ITEMS:

1. DO NOT DISCLOSE PT INFORMATION, JUST CONFIRM IT
2. IS AN APARTMENT OR A HOUSE?
3. PLEASE GIVE ME A SECOND PHONE NUMBER?

Agree

              receipt

              Exam

              account_circle

              Patient Name
            
              phone

              Telephone

              DOB

              payment

              Insurance

              local_hospital

              Refering Doctor

              Other Refering Doctor

Free Typing

Note

APPOINTMENT NOTE DATA:

Questions

DX:

FIBROCYSTIC

YES

NO

PAIN

YES

NO

MASS OR LUMP

YES

NO

ABNORMAL MAMO

YES

N/A

ADITIONAL VIEWS

YES

N/A

LAST MAMMO WITH US

YES

NO

Where

When

When

DO YOU HAVE PRIORS?

YES

NO

DO YOU HAVE IMPLANTS?

YES

NO

REMEMBER:

THE PATIENT SHOULD NOT HAVE A MENSTRUAL CYCLE ON THE DAY OF THE MAMMOGRAM APPOINTMENT.

RX ON FILE

PT HAS RX PLEASE SEND THE RX BY SMS 833/204-5444 OR SCHEDULING@VITALIMG.COM

DR OFFICE HAS RX

FROM DOCTORS OFFICE WILL FAX PRESCRIPTION

N/A

TRANSPORTATION

YES

APPROVED BY:

N/A

NO

SPECIAL NEEDS
IF THE PATIENT HAS SPECIAL NEEDS THEY MUST HAVE REDUCED MOBILITY AND BE ABLE TO ACCESS THE MACHINE BY THEMSELVES OR WITH THE MINIMAL HELP OF A COMPANION
WHICH SPECIAL NEED?

NO

N/A

AWARE OF COMPANION SPECIAL NEED ADULT PERSON WHO CAN DRIVE

YES

NO

PREPARATION

DON'T EAT FOR 5 TO 6 HORAS BEFORE THE EXAM; TAKE MEDICINE WITH MINIMUM OF WATER.

HOW SCHEDULE THIS APPOINTMENT AND EXAM INFORMATION

PT AWARE OF PREPS

YES

NO

CHECK VIEW APPOINTMENTS
SELECT THE CORRECT PATIENT
CHOOSE THE FACILITY

CLOSING

Date

Time

Exam

CENTER ADDRESS

Miami

Homestead

Coralway

Hialeah

Doral

North Miami

Preparation

Rx

Photo ID

Insurance Card

Priors

Do Not Bring Jewelry, Any Metal Objects Or Any Valuable Items Because The Centers Will Not Be Responsible For Them

The day before the apppointment we will call you
to confirm all this information and copay, if it is necessary.
For transportation: On the day of the appointment we
will call you 60 minutes before to confirm the exact pick up time
Farewells: Is there something else, Can I help you with?.
Thank you for choosing Vital Imaging

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Demographicsinfo_outline

WHEN YOU START THE DEMOGRAPHIC PLEASE INCLUDE THESE ITEMS:

Note

Questions

Demographics