Are you a female that is over 40 years of age?

Yes No

Do you currently have any new concerns such as Lumps or Localized Pain?

Yes No

Were you diagnosed with breast cancer less than 2 years ago?
Yes No

Have you breast fed in the last 6 months?
Yes No

Have you seen a provider in the last 3 years?
Yes No

Most insurance companies will not cover a self-referring mammogram prior to one year since the last exam. Please keep this in mind when scheduling your appointment. I acknowledge this warning:
Yes No

Would you like to schedule a Tomosynthesis (3D) exam?

Tomosynthesis (3D) mammography is a way to improve the performance of your mammogram. It allows the doctor to look at breast tissue in thin layers. This detailed view makes it easier to find changes that may be hidden from view by normal tissue on a standard mammogram. It can also lower the chance of having extra tests.

Yes No

Do you use a wheelchair or need extra help?
Yes No

Do you have breast implants?
Yes No

Who is the physician that should receive the results of your mammogram?*
Enter First and Last name:

*Required

Have you had a breast imaging procedure performed before (Mammogram, Breast Ultrasound, or Breast MRI) at a facility other than Bronson?
Yes No

Where did you have it performed?*

*Required

When did you have it performed:*

*Required