west hollywood senior center - breast cancer SCREENING EVENT

plummer park 7377 santa monica blvd. west hollywood, ca 90046

WEDNEsDAY, MAY 16, 2017 (9AM-2PM)

Mobile Mammography

Please fill out the following information to schedule your mammogram. Please call to schedule your appointment at (844) 674-1295.  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 applicable
  • 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

Name *
Phone *
Where can we reach you to verify appointment / insurance information?
Your exam should take an average of 15 minutes. Please select a preferred start time between 10am-1pm. If your preferred time is not available, our office staff will call you to offer alternate times:
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? *
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