Brentwood school | breast cancer SCREENING EVENT 

Monday, oct 15, 2018 (9AM-2PM)

100 s. barrington place, Los Angeles, CA 90049

Mobile Mammography

Employees and their female spouse/significant other are welcome to make an appointment for a complimentary mammogram. Women are encouraged to receive their routine mammogram starting at age 40. However, if you are under 40, Alinea Medical Imaging will still provide a screening as long as you sign a consent form (found in the patient paperwork packet) on the day of your appointment.

Please fill out the following information to schedule your mammogram. Our staff will contact you within 2 business days to confirm your appointment time.  Prior to your appointment, please prepare the following:

  • Download and fill out the necessary patient paperwork

    • Please fill out ONLY the highlighted areas on the Patient Registration Form (PG. 1 of PDF)

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
Phone *
Phone
Where can we reach you to verify appointment?
Appointment Time (9 AM - 2 PM) Your exam should take an average of 15 minutes. If your preferred time is not available, our office staff will call you to offer you an alternative appointment times.
Mammography Information
Are you a female over 35? *
Screening mammograms are encouraged for women over 40 years of age with no symptoms, however baseline screenings can be done at age 35+ if you have family history.
Has it been at least one year since your last mammogram? *
Do you have breast implants? *
INSURANCE / PAYMENT INFORMATION
Your employer has graciously agreed to cover your mammogram exam.