Schedule Bring A Friend Mammogram Appointment

Bring A Friend Mammogram Appointment
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Primary Care Doctor/Provider*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Cell Phone
Email*
Please indicate below the best way our representatives can get in touch with you:*

Home PhoneCell PhoneEmailDoesn't Matter
Are you a current CRL patient or a new patient?*

I'm a new patientCurrent patient
Which technology do you prefer?*

2D (Digital) Mammography3D Mammography (Tomosynthesis)Would like to learn more
Please note: Some insurance providers do not cover 3D Mammography. Please check with your provider prior to your appointment.
What is your age?*

Under 3535 or Over
Have you had a mammogram in the last 12 months?*

NoYes
Please select if you have any of the following*

ImplantsAny Breast SurgeryAny Special Needs (i.e. Hearing/Visually Impaired)Need an InterpreterNone of These
Please specify your breast surgery(s)
Please specify your special needs
Are you pregnant or may be pregnant?*

NoYes
Have you nursed in the past 3 months?*

NoYes
Is this an annual mammogram or do you have new concerns?*

AnnualNew Concerns
Briefly explain your new concerns below:
Bring A Friend mammogram appointments will be scheduled for the same date and time. Please select the options below that will work for both of you. Once your appointment is scheduled we will contact your friend to confirm and collect the necessary information.
Name of friend attending appointment with you:*

First NameLast Name
Friends Phone Number*
Please enter a valid phone number.
Additional Names

Check here if you have additional friends joining you
Second Name:

First NameLast Name
Second Phone Number
Please enter a valid phone number.
Third Name:

First NameLast Name
Third Phone Number
Please enter a valid phone number.
Would you prefer your appointment be the first available or on a specific date?

First AvailableSpecific Date (to be indicated below)
1st Choice Date*

MonthDayYear
Date
2nd Choice Date*

MonthDayYear
Date
3rd Choice Date*

MonthDayYear
Date
Time of Day

MorningAfternoon
How did you hear about us?*

FriendEdina MagazineLake Minnetonka MagazineFacebookInstagramGoogle AdOther - Please Specify
Please specify
Terms & Conditions
By checking this box you agree to have submitted nonfraudulent information. CRL is not responsible for loss of information submitted through this online secure form
CAPCHA*
Should be Empty:

Bring A Friend Mammogram Appointment

Terms & Conditions