Mammothon Appointment Request
Would you like to schedule your Mammogram during MAMMOTHON on October 20?
Yes! I'd like an appointment on October 20.
I'd like to schedule my mammogram on another day.
Please submit your answers below. A team member from the Northwest Breast Care Center will reach out within 24 hours to schedule your appointment.
Name
*
First Name
Last Name
Mobile Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you had a mammogram in the past?
*
Yes
No, this is my first
Date of Last Mammogram
*
Location of Last Mammogram
*
Do you have insurance?
*
Yes
No
What type of insurance do you have?
*
Preferred Screening Location
*
Northwest Hospital Breast Care Center
Advanced Radiology - Pomona Square
Carroll Hospital – Advanced Radiology Fisher
Preferred Appointment Time - Pomona (8 a.m. - 3:30 p.m.)
*
Morning
Early Afternoon
Late Afternoon
Preferred Appointment Time - Carroll (8 a.m. - 6:30 p.m.)
*
Morning
Early Afternoon
Late Afternoon
Evening
Preferred Appointment Time - Northwest (7 a.m. - 5 p.m. )
*
Morning
Early Afternoon
Late Afternoon
Early Evening
Submit
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