QPC Mammogram Screening Refusal Form

Refusal Form

Mammogram Screening

that it is recommended to have a mammogram performed every two years for patients between the ages of 50 and 74 years old. Mammography is a low-dose x-ray of the breast used to detect breast cancer early, when it is most treatable, and has been shown to reduce mortality from breast cancer. No other imaging technique is a substitute for mammography. Mammography is still advised even after a unilateral mastectomy.

I understand that without mammography, potentially cancerous masses or lesions may go undetected and untreated.

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