Our lady of la vang church | mammogram screening event

sunday, november 17, 2019

8:00 AM - 1:00 PM

Our Lady of La Vang Church

288 S. Harbor Blvd., Santa Ana, CA

MAMMOGRAm in 15 minutes!

Please fill out the following information to schedule your mammogram. If you do not have health insurance, Alinea can enroll you in the Every Woman Counts (EWC) program to see if you qualify for a free 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.


Appointment Form

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.

Name / Nombre *
Name / Nombre
Phone / Numero de Telefono *
Phone / Numero de Telefono
Where can we reach you to verify appointment / insurance information?
Please choose your preferred appointment time. If your appointment time is not available, our scheduler will call you to offer an alternate time. Por favor, elija la hora de su cita preferida. Si la hora de su cita no está disponible, nuestra planificadora se comunicará con usted para ofrecerle un horario alternativo.
Mammography Information / Informacion de Mamografia
Are you a female over 40? / ¿Eres una mujer mayor de 40 años? *
Screening Mammograms are typically covered by Insurance if you are over 40 years.
Has it been at least one year since your last mammogram? / ha pasado un año desde su última mamografía? *
Do you have breast implants?/ ¿tienes implantes de los senos? *
INSURANCE and/or PAYMENT INFORMATION / seguro médico y / o información de pago
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