LUMENTUM | breast cancer SCREENING EVENT 

wednesday, October 16 (9:30 AM - 2:30 PM)

400 N. MCCARTHY BLVD, MILPITAS, CA 95035

*Southside of building near outdoor tables between buildings 400 & 430 (outside innovation lounge)

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
DOB *
DOB
Please fill out your Date of Birth in month/day/year format. For example August 30, 1970 would be 08/30/1970 Thank you.
Phone *
Phone
Where can we reach you to verify appointment / insurance information?
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. *PLEASE DO NOT SELECT APPOINTMENTS BETWEEN 12:00 - 12:45 PM, AS THIS WILL BE THE TIME OUR STAFF WILL BE ON THEIR LUNCH BREAK.
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