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Breast Clinic Appointment Request


Patient Information


Other Details


Yes
No
Nipple discharge
Retraction of nipple
Dimpling of skin
Redness of skin
Yes
No
Yes
No
Birad 0
Birad I
Birad II
Birad III
Birad IV
Birad V
Birad VI
N/A
Birad 0
Birad I
Birad II
Birad III
Birad IV
Birad V
Birad VI
N/A
Carcinoma (malignant)
Other (benign)