that they recommended a mammogram at least every two years for patients between the ages of 50 to 74 years old. Mammography is the process of using a low dose amplitude x-ray to examine the human breast and is used as a screening tool. The goal of mammography is the early detection of breast cancer, typically through detection of characteristics masses and/or micro clarifications. Mammography is thought to reduce mortality (death) from breast cancer. NO other imaging technique has been shown to reduce risk. If you have an active diagnosis of breast cancer and/or have had unilateral mastectomy. It is STILL advised that you have a screening mammogram of the existing breast.

I understand that without mammography the detection of masses, lesions, or clarifications in the breast tissue will not be identified, these masses, lesions, or clarifications can be cancerous which would require further evaluation or treatment.

I confirm with my signature below that: The physician has discussed and the above information with me that I have had the chance to ask questions and that all my questions have been answered to my satisfaction and that I voluntarily refuse further testing in the form of mammography.