american airlines | breast cancer SCREENING EVENT 

Tuesday - 05/07/2019 8:00 AM - 12:00 PM 

WEDNESDAY - 05/08/2019 12:00 PM - 4:00 PM

LAX - 1 World Way, Los Angeles, CA 90045

Please fill out the following information to schedule your mammogram. Our staff will contact you within 3 business days to confirm your appointment time.  Prior to your appointment, please prepare the following:

  • Download and fill out the necessary patient paperwork

  • Bring a valid photo ID and Insurance Card

  • If you have had any prior mammograms at another facility, please bring them with you for comparison purposes.

PRIVACY: This is a secure site, all information remains confidential, federal (HIPAA) and state privacy law compliant AND will not be shared for any other purposes other than intended e.g. breast cancer screening as requested.

Appointment Form

PATIENT INFORMATION
Name *
Name
Date of Birth *
Date of Birth
Please enter Date of Birth in MM/DD/YYY format.
Phone *
Phone
Where can we reach you to verify appointment / insurance information?
Please select your mammogram appointment date:
Your exam should take an average of 15 minutes. Please select preferred day and start time. If your preferred time is not available, our office staff will call you to offer alternate times. *Appointments on May 7th are between 8 AM - 12 PM **Appointments on May 8th are between 12:00 PM - 4 PM
Mammography Information
Are you a female over 40? *
Screening Mammograms are typically covered by Insurance if you are over 40 years.
Has it been at least one year since your last mammogram? *
Do you have breast implants? *
INSURANCE / PAYMENT INFORMATION
Our staff will need your photo ID and insurance card on the day of the event. If you are self-pay, please bring a Credit Card with you.
If none, write n/a