Medical Diagnostic Imaging, Diagnostic Imaging Center

The American Cancer Society continues to recommend annual screening using mammography and clinical breast examination for all women beginning at age 40.

To schedule a screening mammogram, fill out the form to the right or call us at 866 558 4320

Mammography Schedule Form - Items marked with * are required.

First Name*

Last Name*

Date of Birth (MM/DD/YYYY)*

Phone Number *

Email Address* Enter Email

Confirm Email

Physician's First Name*

Physician's Last Name*

Confirm Physician Order* By checking this box, you acknowledge that an order from your physician is required for your scheduled Screening Mammogram. Your physician must submit an order to Imaging Healthcare Specialists prior to your scheduled Mammogram. This may be faxed to 866.558.4329 or submitted electronically through the physician portal/EHR.

Insurance Provider

Insurance ID

Screening Questions* Do you have a personal history of breast cancer or are you currently experiencing any of the following conditions: Focal breast pain, Palpable lump or Nipple discharge? No Yes

Do you have breast implants? No Yes

Are you pregnant? No Yes

Choose A Location*

Please note that most insurance companies cover only 1 screening mammogram per year. Please make sure you schedule your appointment 1 year and 1 day after your previous mammogram.

Select Day* Available Dates In Pink

Select Available Time*

Knowledge is powerful.

Getting a mammogram can help you detect cancer early, when it is most easily treated. So partner with Imaging Healthcare Specialists —
a little warning may be all you need to save a lifetime of rewards.

The American Cancer Society continues to recommend annual screening using mammography and clinical breast examination for all women beginning at age 40.

Mammography Schedule Form - Items marked with * are required.

Knowledge is powerful.

Getting a mammogram can help you detect cancer early, when it is most easily treated. So partner with Imaging Healthcare Specialists — a little warning may be all you need to save a lifetime of rewards.

The American Cancer Society continues to recommend annual screening using mammography and clinical breast examination for all women beginning at age 40.

Mammography Schedule Form - Items marked with * are required.

Getting a mammogram can help you detect cancer early, when it is most easily treated. So partner with Imaging Healthcare Specialists —
a little warning may be all you need to save a lifetime of rewards.