Mammogram Appointment Request
Thank you for requesting your appointment for a Screening Mammogram. Yearly screening mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health, as recommended by the American Cancer Society.

If any of the following apply to you, please do not use this form as we require additional information in order to schedule your appointment. Please call one of the breast centers to schedule your diagnostic mammogram appointment.

This applies to:
• Women with a serious breast problem such as a lump, thickening, bloody discharge from the nipple, recent inverted nipple, “orange peel” texture to the skin, redness or discoloration of the breast or any other recent changes that are not normal for the patient.
• Women who are under the age of 35.
• Women with a personal history of breast cancer.
• Women coming back for the first mammogram after having breast surgery for any abnormal condition.
• Women coming back for a follow-up mammogram less than 12 months from their most recent normal mammogram.
Please fill out the form below so that we may provide an appointment that best fits your mammography needs.
(*) Indicates Required Field
First Name:*
Last Name:*
Date of Birth:* (MM/DD/YYYY)
Zip Code:*
Email:*(we will keep your email completely private)
Daytime Phone:*(xxx-xxx-xxxx)
Nighttime Phone:(xxx-xxx-xxxx)
Insurance Provider:*
Choose a location from the drop-down list below. Appointments are available Monday through Friday. Please request a date at least two weeks in advance of today, in case we need to locate additional information or previous mammogram films. Choose the month, date and time that best suits your schedule. We will respond to your request within the next 24 - 48 business hours to confirm your appointment. If your doctor requests that you schedule a diagnostic mammogram or other breast imaging service, please contact the centers directly by telephone to schedule.
Choose the Northern Virginia location nearest you from the drop down list below:*
If you would like to schedule a 3D Mammogram please click on the available location below:
Month:*
Date:*
Time:*
Your Physician Name: