Appointment Request: Mobile Mammography Unit

Would you like to schedule a screening mammogram on our Mobile Mammography Unit? We're currently booking appointments for screening mammograms for Sept. 10 at the Athens Chamber. Please fill out the following form with your preferred appointment time and one of our staff will be in touch to confirm your appointment. * Please note: A woman is eligible for a screening mammogram on the mobile mammography unit if she: is age 40 or older. is between the ages of 35 and 40 and has a family history of breast cancer, i.e., mother, sister or daughter. is not pregnant or nursing (for the last 9 months). is not experiencing any breast symptoms, such as a lump, drainage or breast pain. has seen a referring physician and had a clinical breast exam within one year. has not had a mammogram within the past 12 months or 365 days (unless otherwise approved through insurance company).
* Indicates required information
First Name *
Last Name *
Any Other Name You've Used (Maiden, etc.)
E-mail Address
Date of Birth *
Physician *
Street Address 1 *
Street Address 2
City *
State *
Zip *
Insurance Company *
Name of Insured (Member or Subscriber) *
Insurance ID Number (Policy Number) *
Insurance Group Number *
Insurance Plan ID *
Primary Phone Number *
Secondary Phone Number
Please select your first choice for an appointment timeframe. *
Please select your second choice for an appointment timeframe. *