It is very important that you follow these simple instructions carefully to ensure that your thermographic examination is accurate. If you cannot comply with any of the protocols listed below, please call the office prior to your appointment to discuss the matter and receive further instructions.

1. You should not be sunburned or have fever at the time of your examination. Avoid sunbathing or sunbeds for 5 days prior to your scan.
2. You should avoid chiropractic care, physical therapy, massage therapy, acupuncture, analgesic creams or balms, magnets or poultices for 24 hours prior to your examination. Avoid any physical stimulation of breasts for 24 hours before your scan.
3. Do not shave your underarms within 24 hours prior to your examination. (if you wax your underarms, please avoid waxing for 7 days before your scan)
4. Male patients must shave their chest 24-48 hours prior to the scan.
5. If possible, avoid anti-inflammatory drugs until after your scan. If you are taking Beta- blockers, and are having a breast scan, if possible, hold off on the day until after your scan (a morning appointment may be more suitable for you if this is the case).
6. Do not smoke cigarettes, chew tobacco or use any products which contain nicotine on the day of your examination unless ordered by your doctor
7. Do not use creams, lotions, deodorants, talcum powder or other skin products on the day of your scan. (your underarm and breast areas)
8. You should not drink coffee, tea, soda or other beverages containing caffeine (includes chocolate) for 4 hours prior to your exam. Please note eating is allowed.
9. Do not perform any rigorous exercise program for at least 4 hours prior to your
10. Do not bathe or shower in HOT water for at least 4 hours prior to your
11. Do not wear a bra for at least 4 hours prior to your examination. Please note this includes sports bras or any breast support compressing the breasts.

We do not recommend breast thermography if:

• you had a mastectomy. (this includes single-sided mastectomy)
• you have had a breast lumpectomy within 3 months of the procedure.
• you have had a breast reduction/enlargement within 3 months of the procedure.
• you have had a breast biopsy (including needle biopsies) within 3 months of the procedure.
• you have had radiotherapy in the last 6 months of the procedure.
• you are breast feeding or pregnant. We advise breast thermography 6 months after stopping breast feeding.

I certify that I have complied with the above protocols and preparation instructions. If I have accidentally violated one of the above protocols that leads to cancellation of my scan, I understand that a missed appointment fee (50%) will be applied.

CONSENT FORM FOR THERMAL SCREENING

Infrared Imaging or Thermography is a non-contact, non-invasive test that helps reveal specific physiological patterns of your body. It is not a stand-alone or diagnostic test and it does not replace any recommendation given to you by your General Practitioner, Consultant or other healthcare provider for other forms of breast screening (e.g. mammograms). This information provided by your Thermogram is combined with your history, to enable your health care provider to plan an approach to your care.

A licensed medical practitioner is the only qualified person able to formulate your diagnosis. He or she must combine the thermographic studies with your additional clinical and testing information to determine your condition or diagnosis. Thermograms provide evidence of thermal asymmetries that may be present. An asymmetry may be indicative of a vascular, muscular, inflammatory or other physiological problem.

If food supplements are recommended by your physician, I consent to the self-administration of oral supplements and authorise that these will be prescribed by the physicians at The Natural Doctor_®. I acknowledge that there are no guarantees or assurances made with respect to the benefits breast health therapy prescribed for me. I understand that I will be in charge of administering any prescribed supplements. I will confirm and comply with the recommended doses and methods of administration.

I understand that further testing can be recommended. I agree to comply with requests for further testing (where this is necessary) to assure proper monitoring of my breast health. I agree to report to the physicians any adverse reaction or problems that might be related to my therapy. I understand that there may be possible risks and complications if I do not comply with the recommended dosage.

I have been informed that insurance companies do not pay for this type of therapy at The Natural Doctor_®. I therefore agree to pay for all the services including breast thermography, laboratory and pharmacy and supplementation charges myself, with the understanding that it is unlikely that I will be reimbursed by my insurance company.

I have read the above information and I understand that I am not receiving a diagnosis of any condition based solely on my thermogram. I understand that a thermogram is non-invasive and is reading the thermal patterns on the surface of my body. From this information a qualified practitioner will interpret any thermal abnormality displayed. I have had all the information given to me about my scanning and that I fully understand the above and hereby request and consent to the procedures offered at The Natural Doctor_®.

I understand that if I require a chaperone, I will inform the team at The Natural Doctor_®.