PATIENT FORMS
To protect your privacy, we do not collect or store data on our website. Therefore, in order to complete our below forms, please use the following instructions.
1. You will need to download and open the forms using Adobe Acrobat Reader on your computer. If you do not have Adobe Acrobat Reader on your computer system, you can download a free version here.
2. Use your mouse to right-click on the form icon/link and download the PDF directly to your computer
3. Open the form in Acrobat Reader
4. You will then be able to fill-in the fields and print the form to take with you to Central Florida Breast Center. For your records, please feel free to save a copy of your completed form to your computer.
New Patients
Mammograms
If you are here for a Mammogram please fill out the form below.
Complete this form and sign, the lower part of the form is for office use only.
Clinical Evalutions
If you are here for a Clinical Evalutions or ultrasound please fill out this form.
HIPPA/Privacy Notice
We are required by law to maintain the privacy of your health information and to give you our Notice of Privacy Practices (this “Notice”) that describes our privacy practices, legal duties and your rights concerning your medical information. Your health information includes your individually identifiable medical, insurance, demographic and medical payment information. More information about our policy can be found here.
We collect information from you when you fill out a form.
When ordering or registering on our site, as appropriate, you may be asked to enter your: name, e-mail address, mailing address or phone number. You may, however, visit our site anonymously.
Any of the information we collect from you may be used in one of the following ways:
To improve customer service (your information helps us to more effectively respond to your customer service requests and support needs)
We implement a variety of security measures to maintain the safety of your personal information when you enter, submit, or access your personal information.
We offer the use of a secure server. All supplied sensitive/credit information is transmitted via Secure Socket Layer (SSL) technology and then encrypted into our Database to be only accessed by those authorized with special access rights to our systems, and are required to keep the information confidential.
After a transaction, your private information (credit cards, social security numbers, financials, etc.) will not be stored on our servers.
Yes (Cookies are small files that a site or its service provider transfers to your computer’s hard drive through your Web browser (if you allow) that enables the sites or service providers systems to recognize your browser and capture and remember certain information.
We use cookies to compile aggregate data about site traffic and site interaction so that we can offer better site experiences and tools in the future.
If you prefer, you can choose to have your computer warn you each time a cookie is being sent, or you can choose to turn off all cookies via your browser settings. Like most websites, if you turn your cookies off, some of our services may not function properly. However, you can still place orders by contacting customer service.
We do not sell, trade, or otherwise transfer to outside parties your personally identifiable information.
This does not include trusted third parties who assist us in operating our website, conducting our business, or servicing you, so long as those parties agree to keep this information confidential. We may also release your information when we believe release is appropriate to comply with the law, enforce our site policies, or protect ours or others rights, property, or safety.
If we decide to change our privacy policy, we will post those changes on this page.
This policy was last modified on July 10, 2013
If there are any questions regarding this privacy policy you may contact us using the information below.
2200 Glenwood Drive, Suite 201
Winter Park, Florida 32792
Contact
CFBC@mybreast.com
407-740-5127
www.mybreastdoc.com