Request Your Appointment

Thank you for your interest in a Mammogram at Hancock County Health System.  Please complete this form and we will email you an appointment time.

* Asterisk indicates a required field.

First Name^*

Last Name^*

Email Address^*

Phone^*

How would you like us to contact you with your appointment time?

email
phone

Date of Birth^*

Name of Insurance Company

Primary Care Provider^*

Health Information

Do you have any new breast complaints since your last mammogram? (If yes, please describe)^*

Do you have breast implants?

Yes
No

Do you have any physical or mental limitations? (If yes, please describe)^*

Is this your first mammogram?

Yes
No

Have you had breast cancer?

Yes
No

Have you had a mastectomy?

Yes
No

Have you had a lumpectomy?

Yes
No

Do you speak English?

Yes
No

If you do not speak English, what language do you speak?

Appointment Preferences 

What day(s) of the week would you prefer for your appointment? (Please check all that apply)

Monday

Tuesday

Wednessday

Thursday

Friday

What time of day would you prefer for your appointment? (Please check all that apply)

Before 9:00 AM

9:00 - 10:30 AM

10:30 - Noon

1:00 - 3:00

3:00 - 5:00

Would you like a 3D or 2D Mammogram (Please note: not all insurance providers cover the additional cost of 3D. Please check with your insurance policy)

3D
2D

I agree to Terms and Conditions