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Novant HealthPresbyterian Healthcare (An affiliate of Novant Health)

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Screening Mammography Appointment Scheduling Form

Step 2 of 2: Screening Mammography Appointment Information

Dear Patient: Novant Health is concerned about the privacy of your personal and medical information, our Appointment Scheduling forms are encrypted for complete security of any information submitted through our forms. Please complete the following information in full to schedule your screening mammogram.

* - Denotes required fields

Screening Mammography Appointment Information:

First Name:* Middle Initial: Last Name:*

Date of Birth (mm/dd/yyyy):* / /

Email Address: *

Confirm Email Address: *

Home Phone Number:* - - Work Phone Number: - - ext:

Other Phone Number: - - Type of Phone:

Address:*

City:* State:* Zip:*

If you have had a screening mam in the past has it been at least a year since your last screening?* Yes No

Do you have any new breast lumps or problems with your breast?* Yes No
Please note that for new problems or lumps a diagnostic mammogram will need to be performed.
Diagnostic mammograms will require an order from your physician.

Do you have breast implants?* Yes No

Name of Physician to send the report to: *

Please select your preferred location(s) (*hold down the CTRL key to select multiple choices):

Use this section to select first available date or a specific date from the calendar:

Prefered Date: First Available OR Month Date Year

Use this section to select a specific day of the week and time of day preference:

Preferred Day of the Week: Preferred Time of Day:

Please click the Submit Botton only once.

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