LifeBridge Health Mammothon

LifeBridge Health Mammothon

PREPARATION INSTRUCTIONS

Please arrive 15 minutes prior to your scheduled appointment time. Please bring photo ID and insurance card with you to the appointment. Do not wear any powder, perfumes or deodorants under your arm or breast area. For their safety, unsupervised children are not allowed to remain unattended in our waiting room.

Last Name*

First Name*

DOB*

Contact Number*

Phone

E-Mail Address*

Insurance Information or Uninsured?*

Advanced Radiology Member?*

Yes

Advanced Radiology ID#

Have You Ever Had A Mammogram?*

Yes

Date of Last Mammogram*

Location of Last Mammogram*

Are You Having Any Problems At This Time?*

Are you having any problems with your breast such as new lump, nipple discharge or breast pain? (if breast pain specific area and duration?)

Yes

PLEASE COMPLETE FORM AND SUBMIT. SEE NOTES BELOW.

If the patient answers yes to any of these questions, the patient is not a candidate for a Screening mammogram.

This patient should be scheduled for a Diagnostic mammogram and would need to have an ordering provider for this exam.

Please have the patient call the Advanced Radiology Contact Center at 1-888-972-9700 to follow up and schedule the Diagnostic mammogram.

Previous Breast Cancer or Surgery?*

Yes

Date Diagnosed*

Do You Have Implants*

Yes

Are You Pregnant or Nursing?*

Yes

Order or Self-Screen*

Physician Order for Screening

Self-Referral

Referring Physician*

Referring Physician Location (Street Address)*

Preferred Location*

Carroll Hospital - Advanced Radiology (Fisher Bldg)

Grace Medical Center - Imaging Center

Northwest Hospital - Breast Care Center

Sinai Hospital - Imaging Center

Clicking "Submit" will take you to AppointmentPlus where you can choose your time and location.

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