Brentwood school | breast cancer SCREENING EVENT 

Monday, oct 23, 2017 (9AM-2PM)

100 s. barrington place, Los Angeles, CA 90049

Mobile Mammography

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
  • 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
Phone *
Phone
Where can we reach you to verify appointment / insurance information?
Your exam should take an average of 15 minutes. Please select preferred start time. If your preferred time is not available, our office staff will call you to offer alternate 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 offered to cover your mammogram in full if you meet the above guidelines for a screening.