Mammography Scheduling Request Form

Please complete this form to schedule your next mammogram.  If you prefer to speak with someone to request an appointment, please contact our scheduling department at 706-389-2700.  Thank you for choosing St. Mary’s for your breast health care. Your health is our mission.

Patient Information

(Please enter full legal name)

Date of Birth*

(A written order is not required for an annual screening mammogram)

Are you having any type of problems with your breasts?*
 Nipple Discharge
 New/unexplainable pain
 Skin changes
 Personal history of breast cancer
 Other  (please specify)
 (Additional imaging time may be required)
(i.e. abnormal mammogram)

Insurance requires 1 year and 1 day since your last screening mammogram
Scheduling Information
All appointments will be scheduled according to your preferences outlined below:

Please select approximate date for appointment:
  Check all that apply
 Monday   Tuesday   Wednesday   Thursday   Friday   Saturday**  
**Saturday appointments are available from 8am-12pm only at Outpatient Diagnostic Center.
  Check all that apply

 8am-10am   10am-12pm   12pm-2pm   2pm-4pm   4pm-6pm  

 E-mail   Phone  

Additional Information or Comments / Special Requests