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Patient: _______________________________ Phone: _____________ DOB: __________
Address:_______________________________ City:_______________ State:____ Zip Code:_______
Patient Requires:
□ Breast Prosthesis, Silicone – 1 per side every 2 years
□ Mastectomy Bras – 3 every 4 months
□ Breast Prosthesis; Leisure (Non-weighted) Form – 1 per side every 6 mths
□ Post-Op Camisole – Post-Op misc.- 2qt
□ Lymphedema Garments- Sleeve ____ Glove_____ Knee ____ Thigh _____ Panty Hose ______
Compression Level: 15-20 ___ 20-30_____ 30-40_____
Frequency of Use:
□ Daily: ____ □ Weekly: ____ □ Monthly: _____ □ Lifetime: ____
Diagnosis:
Cancer Lymphadema Diagnosis Code:
Rt Breast ____ Lt Breast ____ S/P Mastectomy___ RT ___ LT ___ _______________
Date Of Surgery___________
Clinical Status:
No Change ____ Improving _____ Declining _____
Any Further Breast Surgery Type: ____________ Date: _____________ Prognosis: ___________________
Date of Last Breast Exam: ___________________
Limitations: ______________________________________________________________________________
EXPLANATION/CLARIFICATION-Necessity of Above-Mentioned Item
:__________________________________
________________________________________________________________________________________
________________________________________________________________________________________
* Also any other notes pertaining to this condition.
_________________________________
PHYSICIAN’S SIGNATURE
*required every 12 months
_____________________________
PRINTED NAME
________________
DATE
Intimate Image 22941 Ventura Boulevard | Woodland Hills | CA 91364 | Phone: 818-876-7333 | Fax: 818-876-7334
2907 1/2 Santa Monica Boulevard | Santa Monica | CA 90404 | Phone: 310-582-1960 | Fax: 310-582-1972
PATIENT PROGRESS NOTES
Intimate Image Fax #: 818-876-7334 (Woodland Hills) 310-582-1972 (Santa Monica)