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Request a Mammogram Appointment

 

Mammogram Appointment Request Form
  1. Use the form below to request an appointment for a screening mammogram.

    How will my appointment be scheduled?

    Submitting the form does not mean you have scheduled an appointment. Your appointment will be scheduled when you receive a call back from our staff. You will hear back from us within one business day, Monday through Friday between the hours of 8 am and 4:30 pm.

    What if I have questions?

    If you have questions or would prefer schedule an appointment by phone, call 651-232-5500 and select option "2."

    Please keep in mind: Most insurance requires a year and one day between annual mammograms.

    *Required fields

  2. Requestor information

  3. First name*
    Enter the requestor's first name.
  4. Last name*
    Enter the requestor's last name.
  5. E-mail address*
    Enter a valid e-mail address.

  6. Patient information

  7. *


    Select if the patient is the same or different as the requestor.
  8. First name
    Enter the patient's first name.
  9. Last name
    Enter the patient's last name.
  10. Patient date of birth*
    Enter a valid date of birth.
    mm/dd/yyyy

  12. Phone number(s)
  13. Preferred*
    Enter a valid phone number.
    xxx-xxx-xxxx
  14. Alternate
    Invalid Input
    xxx-xxx-xxxx
  15. Health insurance
    Invalid Input
  16. Do you need an interpreter?*
    Indicate if you need an interpreter.

  17. Scheduling an appointment

  18. Appointments are available Monday through Friday at all locations;
    Saturday appointments are available at St. John's and Woodwinds.

  19. Select a location*
    Select a location.
  20. Requested date*


    Request a date.
  21. Select a date using the calendar.
  22. Alternate date
    Select a date from the calendar.
  23. Preferred time*
    Select your preferred appointment time.

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