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.


Phone
Advanced Radiology Member?*
Have You Ever Had A 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?)

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?*

Do You Have Implants*
Are You Pregnant or Nursing?*
Order or Self-Screen*
Preferred Location*

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