HARVARD WESTLAKE SCHOOL

tuesday, november 5th, 2019

Harvard Westlake - Middle School

7:00 AM - 11: 00 AM

700 N Faring Rd, Los Angeles, CA 90077

Harvard Westlake - Upper School

12:00 PM - 4:00 PM

3700 Coldwater Canyon, Studio City, CA 91604

Women are encouraged to receive their routine mammogram starting at age 40. Insurance plans may cover a routine baseline screening starting at age 35. A referral is not required by a doctor.

Women with pain or breast discomfort would need to obtain a referral from the primary care physician (PCP) for a diagnostic mammogram.

Women who are pregnant or breastfeeding should consult with their physician before making an 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

  • Bring a valid photo ID and insurance card

  • Wear a 2 piece outfit on date of your exam

  • If you had any prior mammograms at another facility, please bring your radiology report and CD of your images 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
D/O/B *
D/O/B
Please enter your Date of Birth in MM/DD/YYYY format
Phone *
Phone
Where can we reach you to verify appointment?
Appointments will be split into morning and afternoon slots. 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. *There will be no appointments available between 12:00 PM - 1:00 PM. Staff will be on lunch break*
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 Plan/Payment Details
Please bring a valid photo ID & insurance card with you to your mammogram screening appointment.
Please add any additional information we may need to know below, thank you.