Mammogram Appointment Screening Mammogram is a yearly exam for women 40 and older with no breast problems. We will make every effort to accommodate your preferred appointment day and time. Please bring your prescription to the appointment. Personal Information First Name: Last Name: Date of Birth: Address * Street Address Street address is required City City is required Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana International Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming State State is required Zip Zip Code is required Contact Telephone: Invalid Phone Number Email: Email is required Email is required Invalid Email Address Physician Name: Select Your Preferred Appointment Day and Time First Preference: select... Monday 12 - 6 p.m. Tuesday 7:30 a.m. - 8:30 a.m. Tuesday 12 - 5 p.m. Wednesday 7:30 a.m. - 8:30 a.m. Wednesday 12 - 5 p.m. Thursday 7:30 a.m. - 8:30 a.m. Thursday 12 - 5 p.m. Friday 7:30 a.m. - 8:30 a.m. Friday 12 - 4:30 p.m. Second Preference: select... Monday 12 - 6 p.m. Tuesday 7:30 a.m. - 8:30 a.m. Tuesday 12 - 5 p.m. Wednesday 7:30 a.m. - 8:30 a.m. Wednesday 12 - 5 p.m. Thursday 7:30 a.m. - 8:30 a.m. Thursday 12 - 5 p.m. Friday 7:30 a.m. - 8:30 a.m. Friday 12 - 4:30 p.m. Comments: Comments is required Comments is required Submit