Mammogram Request

To request your routine, annual mammogram, simply complete and submit the form below. We will fax an order to your preferred facility within 48 business hours.

Please use this only for routine screenings. If you have been informed of a need for a diagnostic mammogram, please call our office.

We will work this request and send an order to the center you selected. Please allow 48 hours before checking with the imaging facility. We will contact you only if there are questions or problems.

Thank you