Mammogram Appointment Request

Welcome to the Online Mammogram Appointment Request System. As you complete these pages, you will notice a status bar at the top of your page showing your progress thorough the form.

We are offering a new Mammography Service- If you would like to wait while the Radiologist reads your "Screening Mammogram” please fill out the following patient/physician information and proceed to Appointment Preferences for further information.

  

Patient Information

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First Name:
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Last Name:
Middle Initial:
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Birthdate:
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Street Address:
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City:
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State:
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Zip Code:
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Home Phone:

Format: (123) 456-7890

Other Phone:

Format: (123) 456-7890

Employer Name:
Full Time/Part Time/Retired/Not Employed?
Work Phone:
Gender:

Male or Female

Physician/Procedure Information

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Physician Name:
Physician Phone:
Procedure Information:
Primary Care Physician Name:
Primary Care Physician Phone:

Screening Mammogram Read at Appointment Time

These appointments are offered in the Sparrow Professional Building/Diagnostic Center Women’s Imaging Only Appointment times are on Tuesday mornings from 9:00am - 10:30am. At the conclusion of your appointment you will be given the Mammogram report to take with you for your records.( your physician will also be given a report)

Are you willing to wait for an hour or more so that the radiologist has sufficient time to read your study.

Yes or No

Do you have a copy of your prior mammograms?

If your prior mammograms were not done at a SPARROW facility, you need to bring them with you at time of your appointment.

Appointment Preferences

Please note: Selections below do not constitute a booked appointment. We will do our best to accomodate your first choice for an appointment. Central Scheduling will contact you M-F between 8am-4:30pm.

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Location

Clinton Memorial Hospital (Mon-Fri hours vary)
Okemos Diagnostic Center (8am-3:30pm Mon-Fri)
Sparrow Professional Building (SPB) (7:30am-7:30pm Mon-Thur; 7:30am-3:30pm Fri; 8am-3:30pm Sat.)
Sparrow Ramblewood Imaging Center (8:15am-4:15pm Mon-Fri)
Sparrow Ionia Hospital (8am-4pm Mon-Fri)

(Minimum 7 days notice required for Mammogram Appointment Request Processing)

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Best day of week to call with confirmation:

Any Day, Monday, Tuesday, Wednesday, Thursday, Friday

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Best time to call with confirmation:

Anytime, Early Morning 7-9am, Monday 9am-12pm, Midday 12-3pm, Late Afternoon 3-6pm

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Best phone number to call with confirmation:
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May we leave appointment information on voicemail or answering machine?

Yes or No

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Appointment Day:

Any Day, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday

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Appointment Time:

Anytime, Early Morning 7-9am, Morning 9am-12pm, Midday 12-3pm, Late afternoon 3-6pm

Other Information

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Have you had previous mammograms?

Yes or No

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Has it been at least 12 months since your last mammogram? (Most insurance companies cover one mammogram per calendar year)

Yes or No

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Where were previous mammograms performed?
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Have you ever been diagnosed with Breast Cancer?

Yes or No

When were you diagnosed?

If diagnosed with Breast Cancer over 5 years ago, this is now a SCREENING MAMMOGRAM (If symptomatic, please contact your physician.) If it has been less than 5 years, this is a DIAGNOTSIC Mammogram for a History of Breast Cancer. If the patient has had a Mastectomy, the remaining breast will be a “ Unilateral Screening with CAD” –Regardless of time – ( unless the patient is symptomatic then it would be a unilateral diagnostic)

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Will you need extra time or assistance? (for example: wheelchair bound, require physical assistance, etc.)

Yes or No

Emergency Contact Information

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Do you have an Emergency Contact?

Primary Insurance Information. Be prepared to present insurance card on admission date.

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Do you have insurance?

Secondary Insurance Information: Complete only if a secondary carrier will be billed, otherwise select No Secondary Insurance. Be prepared to present insurance card on admission date.

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Do you have secondary insurance?

Other Insurance Information: Complete only if other insurance carrier will be billed, otherwise, select No Other Insurance. Be prepared to present insurance card on admission date.

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Do you have other insurance?

Please click "Submit" to complete your request.

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