Thermography Forms Links and Pre-Scan Instructions

Thermography Body Scan Client Information Sheet

Thermography Breast Scan Client Information Sheet

Thermography Authorization and Release Form

Ville Marie Thermography Grading Scale

Thermography Pre-Scan Instructions Printable Version


Thermography provides valuable information that may be important to your health and well-being. However, to get the best results, you must follow the pre-scan instructions. So please read these instructions carefully.

If you have any unusual health circumstances or conditions, please let us know well in advance of your appointment. If the discussion is extensive, you may have to schedule a pre-scan consultation with Dr. Campbell if necessary, but there is an additional fee for this consultation. If you have thermographic images from the past from another thermography clinic that you would like Dr. Cambpell to evaluate or compare with the images he will be taking, please advise us of this ahead of time. The comparative analysis is considered a consultation and so falls under the additional consultation fee category.

Pre-Scan Instructions

For the best thermography results, please follow these instructions fully.

Within 5 Days of Thermography
      •    Avoid sunburn. No sun tanning or tanning booth treatments.

Within 2 Days of Thermography
      •    No heavy alcohol consumption.
      •    No X-ray mammography.

Within 1 Day of Thermography
      •    No physical therapy, chiropractic treatments, acupuncture, massage, diathermy, electrical muscle stimulation (EMS),
           nerve stimulation (TENS), or heat/cold therapies. 
      •    No stimulation of breasts if you are scheduled for a breast screening.

After Midnight before Thermography
      •    No alcoholic beverages.
      •    No shaving (or other types of hair removal) in any areas that could be imaged.
      •    No use of deodorants or antiperspirants in area to be imaged or for a breast screening.
         No use of powders, lotions, creams (including hormone) or makeup on the area to be imaged or for breast screening.

Within 4 Hours of Thermography
         Avoid getting overheated. No physical exercise (running, gym workout, sauna, etc.).
         If at all possible, take prescription medicines (especially blood pressure or circulation medications) four or more hours before            having your thermal scan. If you have any questions, consult your primary care physician. 
         Avoid taking any non-prescription medicines, especially cold remedies and niacin, within four hours of your thermal scan.
      •    No smoking or use of other nicotine-delivery products (snuff, gum, patches, electronic cigarettes, etc).
        No very spicy or hot foods.

Within 1 Hour of Thermography
        No showering or bathing. 
      •    No hair dryer use.
         Avoid very hot or cold drinks. Preferably have only room-temperature or lukewarm food and drink.
      •    No breastfeeding.

Within 15 minutes of Thermography
      •    Use the restroom before your cooling period and scan. 
        Nothing to eat or drink.
      •    No gum chewing.

How to Dress for Your Scan

If you are having a breast scan, please dress in loose-fitting two-piece clothing, as you will disrobe only from the waist up.

For partial body scans, you will have to fully uncover the area to be imaged.

For a full-body body scan, you may have to disrobe to your underclothing. Select underclothing that provides maximum exposure of your skin and is form-fitting. For example, men should wear brief-type underwear rather than boxers. 

Coming In for Your Scan

         Follow these Thermography Pre-Scan Instructions beginning five (5) days before the scan.
         Please arrive 15 minutes before your appointment.
        Check in at the front desk. The receptionist will give you a Client Information Sheet to fill out. Once you have completed it,
           return it to the receptionist. (You can download this form from the list at the top of this page and complete it at home to save 
           time.) 
        Arrange payment for the scan.
      •    Use the rest room if needed (recommended so you don’t have to leave the environmentally controlled room during the cooling-              down period).
      •    Please do not eat or drink anything or chew gum. 
        Once you are in the thermography room, please turn off or silence your cell phone or other electronic device. Keep any
           electronic equipment, including your cell phone, away from your body.
          You will be instructed to remove all clothing from above the waist for a breast scan or the necessary clothing for other types of
           scans. Clothes hangers are provided.
         Remove any jewelry from the neck and chest area for a breast exam, including dangling earring and chest piercings. A shelf
           for jewelry items is provided.
        If you have long hair, please tie it back so it is fully up off your shoulders and neck. A hair tie will be provided if you need one.
        For a breast scan, during the 15-minute acclimatization at 68°F, you will lay face up on the exam table (which is a comfortable            padded massage table) with your arms away from your body so all sides of the breasts are exposed to the cool air. Minimize            any talking, Napping is okay. For other types of scans, you will be advised if a different arm/body posture is necessary.
        For a breast scan, do not touch, rub, or scratch your breasts or the surrounding skin during the cooling down or scan periods.
        During a breast scan, images will be taken while you are lying down and also while you are standing. When standing, keep
           your arms away from your body. You also will be asked to move your arms out to the sides and above your head (see
           illustration below) so that different types of images can be taken.

      

Thermography Report, Medical Insurance, and Follow-Up

Your thermograms will be processed, analyzed, interpreted and archived by Dr. Campbell. Within two weeks, and usually much sooner, he will send you the scan report in one of several formats (you specify which you prefer): as an email attachment (PDF) or on a CD by mail. You may also have a copy of your report sent to the healthcare provider of your choice. The report includes the images and the interpretation/results. There is a link at the top of the page for the Thermography Authorization and Release Form.  

Your thermal scans are best viewed on a computer monitor. Printed color images are usually not faithful reproductions. Copies of your report and image are archived at Integrative Life Solutions and, for added preservation and safety, are also backed-up and stored in an offsite archive. You will also receive a printed receipt or a PDF copy of the proper medical diagnosis and procedure codes for insurance reimbursement. Contact your medical insurance company for instructions on how to submit this receipt. An initial written referral order for the thermogram from your primary healthcare provider given to you before you schedule the scan itself may facilitate insurance reimbursement. Please note that not all medical insurance companies cover clinicall thermography.

You will receive a mailed reminder card in one year’s time for a follow-up thermogram. However, depending on the scan results, Dr. Campbell may suggest another scan sooner than one year. Please keep us updated if you have a change of name and/or address.

 

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