Breast Medical Records and Consent Forms

We are happy to provide you with one copy of each breast imaging exam we perform, free of charge. These are your copies to keep – they do not need to be returned to us. Unless otherwise specified, we will provide all requested images on a CD.

**Please note: There will be a charge for an additional copy of any exam we have previously provided to you or your physician.

If you would like us to request your previous breast imaging exam(s) from another facility, please complete the medical records request form and fax it back to us at 214-442-7075, ATTN Medical Records. Please allow 14 days for us to contact the prior facility and receive the requested images.

» CLICK HERE for Medical Records Form

» CLICK HERE for Minor Consent Form

» CLICK HERE for Imaging Consent and Pregnancy Disclosure Form

» CLICK HERE for Mammogram with Implants Disclosure and Consent Form

Office: 214.442.7050
Fax: 214.442.7075

3301 E. Renner Rd
Suite 100
Richardson, TX 75082

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Hours
Monday - Friday
8 - 5


Elizabeth Jekot MD Breast Imaging Center
3301 E. Renner Rd, Suite 100
Richardson, TX 75082

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