Hormone Replacement Therapy Mammogram Waiver Form 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name in the designated field at the top of the form. This identifies you as the patient undergoing therapy.
3. In the section regarding your decision on mammograms, select one of the provided options that best describes your situation by checking the appropriate box.
4. If applicable, ensure to attach a note from your treating physician if they have advised against having a mammogram.
5. Initial next to the statement acknowledging that you understand the risks associated with not having a mammogram while undergoing hormone therapy.
6. Finally, print your name, date, and provide your signature at the bottom of the form to confirm your understanding and agreement.

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