Mammogram Appointment Request

Sparrow offers a variety of mammogram services, including Digital Breast Tomosynthesis (3D mammograms) for screening and diagnostic imaging.

If you have questions about what is right for you, information on Sparrow’s comprehensive Breast Health services, including dense breast tissue and 3D mammography may help.

You can schedule your appointment by calling 1.800.698.6329 or complete the following form. Collecting this information now, at your convenience, will assist our schedulers when they call you to finalize your appointment. Please have your insurance cards and Physician information handy before you begin.

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

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Procedure Information:

You may select either a traditional SCREENING MAMMOGRAM or a 3D MAMMOGRAM. We only schedule 3D’s at Sparrow Professional Building, Sparrow Eaton Hospital (Hayes Green Beach), Sparrow Clinton Hospital, Sparrow Ionia Hospital, or Sparrow Health Center located at 2909 E Grand River.
NOTE: Not all insurances cover 3D mammography.  Please verify your coverage and determine any out of pocket costs prior to finalizing your appointment. 

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Referring Physician Name:
Referring Physician Phone:
Primary Care Physician Name:
Primary Care Physician Phone:

Day of Screening Results

Sparrow offers same day results for select screening mammogram appointments. These appointments are offered at the Sparrow Professional Building in the Diagnostic Center on Tuesday mornings from 9 - 10:30 a.m. At the conclusion of your appointment you will be given the mammogram report to take with you for your records and a copy will be sent to your Physician.

Do you want to wait (could be an hour or more) for same day test results?

If yes, please select Sparrow Professional Building as your desired location below.


Appointment Preferences

Please note: Selections below do not constitute a booked appointment. We will do our best to accommodate your first choice for an appointment. Central Scheduling will contact you Monday-Friday between 8 a.m. and 4:30 p.m. to finalize your appointment.

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Location

(Minimum 7 day's notice required for appointment request processing)

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Best day of week to call with confirmation:
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Best time to call with confirmation:
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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?

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Appointment Day:
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Appointment Time:

Other Information

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Have you had previous mammograms?

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

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Where were previous mammograms performed?
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.


Have you ever been diagnosed with Breast Cancer?

Has it been less than 5 years since diagnosis?

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

Emergency Contact Information

Do you have an Emergency Contact?

Last Name:
First Name:
Date of Birth (if known):
Street Address:
City:
State:
Zip Code:
Telephone:
Employer Name:
Employer Telephone:
Relationship to Patient:
Other relationship:

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

Do you have insurance?

Insurance Company Name:
Address for filing claims: (usually on back of card-please enter N/A for Address, City and Zip Code for Medicare or Medicaid)
City:
State:
Zip Code:
Telephone Number:
Policy Holder's Name:
Policy Holder's Employer:
Policy Holder's Employment Status:
Policy Holder's Relationship to Patient:
Other relationship:
Policy Holder's Date of Birth:
Policy ID Number:
Group Name:
Group Number:

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.

Do you have secondary insurance?

Insurance Company Name:
Address for filing claims: (usually on back of card - please enter N/A for Address, City and Zip Code for Medicare or Medicaid)
City:
State:
Zip Code:
Telephone Number:
Policy Holder's Name:
Policy Holder's Relationship to Patient:
Other relationship:
Policy Holder's Date of Birth:
Policy ID Number:
Group Name:
Group Number:

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.

Do you have other insurance?

Insurance Company Name:
Address for filing claims: (usually on back of card, please enter N/A for Address, City and Zip for Medicare and Medicaid)
City:
State:
Zip Code:
Telephone Number:
Policy Holder's Name:
Policy Holder's Relationship to Patient:
Other relationship:
Policy Holder's Date of Birth:
Policy ID Number:
Group Name:
Group Number:
Please click "Submit" to complete your request.  You will receive a call from Central Scheduling within the next (timeframe) to finalize your appointment.