Carolina Thermascan, L.L.C.
4505 Fair Meadow Lane, Suite 111
Raleigh, NC 27607
Telephone (919) 781-6999 Fax (919) 571-8968
CONSENT FOR BREAST THERMAL IMAGING
I, ______, hereby request and consent to undergo a non-invasive, non-contact procedure called Breast Thermal Imaging. I understand that thermal imaging is an examination of physiology that is complimentary to anatomical imaging techniques. Though proven to be highly accurate, thermal imaging is an adjunctive procedure; and as such, it is not intended to replace anatomic studies such as mammography, ultrasound, MRI, CT, X-ray, or others,
I understand that I have been advised to continue to undergo whatever diagnostic procedures my primary care provider or other physician specialists have recommended. I understand that the information provided by this thermal scan is used along with my medical history and mammogram to enable my health care provider to plan an approach to my care. I also understand that a licensed medical practitioner is the only qualified person to read this scan.
I understand that Breast Thermography is a widely used and accepted procedure among Integrative Health Practitioners, but is not considered a mainstream procedure among most conventional physicians. I understand that Carolina Thermascan, LLC is only a provider of this risk-assessment screening service and is not responsible for any medical treatment or care as a result of the findings from the scan, other than informing me of the findings and making recommendations for follow-up care. I have read the above information and I understand that I am not receiving a diagnosis of any condition based solely on my thermal scan.
By participating in this risk-assessment screening, I acknowledge that this procedure is solely for information and screening purposes. I understand and acknowledge that Carolina Thermascan’s personnel are not physicians and are not rendering medical care or services. I understand that a report of my screening scan is created by a licensed physician with the results being sent to me. I HEREBY FOREVER RELEASE AND DISCHARGE CAROLINA THERMASCAN FROM ANY LIABLITY FOR ANY CLAIMS BASED ON THE FAILURE TO DETECT OR DIAGNOSE ANY MEDICAL CONDITION. I understand that the responsibility for confirming the results of the screening, initiating follow-up care, and obtaining professional medical assistance is mine, and not that of any organization associated with this screening. Carolina Thermascan has instructed me to communicate the screening results and presence of any issues indicated on the Breast Health Questionnaire directly to my own physician.
I understand and acknowledge that CarolinaThermascan does not participate in the Medicare program and that these screening services are not reimbursable by Medicare. I am aware that other insurance providers may not reimburse me for the cost of this test. I understand that payment is due at the time service is rendered. Having been informed of the purpose for the use of breast thermography and how it is not meant to replace any diagnostic tools, I hereby request to undergo this procedure performed by the staff of Carolina Thermascan, LLC.
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Revised 10-13