Breast Health Navigation Services – Pre-Consultation Questions

Pre-Consultation Questions

This form must be filled out prior to your consultation. Please email Jackie Trotter if you have any questions: jackie@mammographyeducators.com

Facility or Hospital (where the training will be held)*

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Facility Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please provide any parking instructions or directions to the building (if applicable) that the consultant should be aware of*

Are there any visitor or vendor requirements that your consultant will need to complete prior to training, such as: sign-in processes, documentation or verification requirements, etc? Please provide specific details, if applicable.*

Is your facility part of a larger organization? If so, please indicate below. If not, put N/A:*

Name of the individual who will be meeting the consultant on the first day of training*

First Last

What is the best contact number for the individual listed above?*

Additional Information

Please provide the contact information of your accounts payable department or whomever processes your invoices. Please list name, phone and e-mail below.*

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Please provide detailed information about each mammography unit at your facility.

For each mammography unit at your facility, please include: the manufacturer, specific model, and next date of accreditation (List unit number with corresponding information and due date in MM/DD/YY format).

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To help prepare your Breast Imaging Consultant(s) before arriving on-site, please let us know the type of mammograms your facility performs.

Only Digital Breast Tomosynthesis (DBT) Mammograms
Only 2D Digital Mammograms
A combination of both

Any additional information/details we should know?

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