Request a Mammogram Screening 2018-01-30T18:06:27+00:00

Request a Screening Mammogram

Request a Screening Mammogram

Thank you for choosing POM MRI & Imaging Centers

Prep for Mammograms
Please wear loose clothing, preferably separate top and bottom. Do not use deodorant, powder or perfume under your arms.

     -  Review the American Cancer Society's Guidelines for breast cancer screening.
     -  Review the Insurance List
     -  Patient Forms

Personal Info

  • First Name*

  • Last Name*

  • Street Address*

  • Address Line 2

  • City*

  • State *

  • Zip Code *

  • Daytime Phone Number *

  • Email Address*

  • Date of Birth*

Symptoms

  • Are you currently having any breast problems at this time? (lumps, pain, discharge, etc)*

    YesNo

  • Have you ever had Breast Cancer?*

    YesNo

  • Do you have breast implants?*

    YesNo

  • Was your last mammography procedure done at a POM MRI location?*

Insurance and Facility

    Insurance Company:*

    Which facility do you prefer?*

    Plantation (4373 West Sunrise Blvd), scheduling@pommricenters.comCooper City (11011 Sheridan Street Suite 101), schedulingcc@pommricenters.com

    Referring Physician that will receive the report: *

    Preferred date of visit

    What day(s) would you prefer to visit?*

    MondayTuesdayWednesdayThursdayFridaySaturday

    What time would you prefer your visit?*

    MorningAfternoonEvening

Questions & Comments

    Message

    Enter the word in the image below*

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