Pre-Consultation Questions 2022 – Mammography Educators

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)*

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*

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?*

The consultant will be bringing a lecture presentation on a USB flash drive. Is a USB flash drive compatible with your computer/projector system? (Please confirm with your IT Department)*

List all technologists participating in this training (Include first name, last name, credentials and email).*

Alternatively, you may send a spreadsheet via email to Jackie Trotter: jackie@mammographyeducators.com

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.*

Please list next date(s) of accreditation for each mammography unit at your facility. (List unit number and corresponding due date in MM/DD/YY format)*

Any additional information/details we should know?

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