Breast QTscan Required Forms

• Paperwork applies to new and existing patients.
• All forms must be completed before scheduling.
• Please also submit any breast imaging from the last 12 months.

Instructions

Option 1: Print forms and fill in by hand.

1. Scan completed documents and email to info@couricenter.com.

OR

Option 2:  Complete forms online as .pdf.

1. Please open each form and save it on your computer. When saving, please add your last name to the file name.
2. Open the saved documents and complete each fill-in form.
3. Save completed documents.
4. Email completed documents as attachments to: info@couricenter.com

Breast QTscan Paperwork

QTscan Medical Intake Form

QTscan Informed Consent Form

QTscan Imaging Procedure Acknowledgment

QTscan Consent to Send to Another Facility

QTscan Cancellation Policy

CANCELLATION POLICY & FEES

Breast QTscan Policy

We value your time and appreciate your cooperation in keeping our schedule running smoothly for all patients.

• Breast QTscan Cancellations – Please provide 48 business hours’ notice for cancellations or rescheduling.
• No-Show Fee – Missed Breast QTscan appointments 10+ minutes late will be charged in full.
• Reminders – We send text and email reminders 2-4 days in advance, but keeping your appointment is your responsibility.