Physician Referral Form

The Rose Galleria Forms

The Rose Southeast Forms

Helpful Tips for your Mammogram:
1. Do not wear lotions, powders or deodorants on the day of your appointment.

2. For a mammogram, please wear two-piece clothing for convenience and comfort. For a biopsy, please do not take any aspirin or Advil for at least 7 days before appointment. For bone density, please do not wear any metal, i.e., zippers or buttons. Please do not bring a child who requires supervision while you are being examined.

3. Please bring the following to your appointment:

• Referral from your physician
• The date of your last menstrual period or year of hysterectomy
• Any previous mammograms/breast ultrasound films for comparison purposes or the address and phone numberof the facility where they can be obtained. This will allow us to quickly compare them to your new films. Your results may be delayed if we must wait for your old films to arrive.
• Any bone density test results or the address and phone number of the facility where they can be obtained.