Online Appointment Form

Appointment Request Form

Thank you for your interest in scheduling a consultation with Dr. Schwartz! Please complete the form below with as much detail as possible. We will call you back at the provided phone number to schedule your appointment. Our office is located at 631 Professional Drive, Suite# 300, Lawrenceville, GA 30046. You can also reach us at our office phone number: 770-962-9977
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Your Height: ft and in
Your Weight: lbs
Bra Size:
Do You Currently Have Implants?

NoYes
IF You Have Implants, Are They:

SalineSilicone
IF You Have Implants, How Old Are They?
Insurance

Please upload below a picture of the front and the back of your primary insurance card and any additional/supplemental insurance cards for a proper benefit verification
Insurance provider *
Please type the name of your insurance provider and subcategory (PPO, HMO, etc)
Insurance card(s)

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BREAST REDUCTION PATIENTS ONLY

Most insurance providers cover breast reduction for medical reasons. Patients inquiring about breast reduction must first verify their benefits with their insurance. Please call your insurance and check if diagnosis code M54.9 and procedure code 19318 are covered under your plan. If breast reduction is not covered, we can provide you with our very competitive self-pay rates.
I have called and verified my breast reduction benefits on:

MonthDayYear
Date
Reason For Visit*
Please provide details
Additional Comments
Scheduling Your Appointment

Dr. Schwartz sees patients on Mondays & Wednesdays 7AM to 3PM, Fridays 7AM to 11AM
Preferred Appointment Time

MorningAfternoonNo Preference
Completed test

MammogramUltrasoundDiagnostic MammogramMRIGenetic TestingBiopsy
Please provide the address and phone number of the facility where your tests were done:
For multiple facilities, please identify what tests were done where
Please provide your primary care and/or medical oncologist contact information:
Please attach any relevant test results or pathology. You can take pictures of your reports, screenshots of your digital files and attach them here. Large files can also be emailed to: mybreastcancerdoc@gmail.com

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By clicking "SUBMIT" below, you give us your permission to request, review and discuss your medical history and test results with your providers.
Should be Empty:

Appointment Request Form

Insurance

BREAST REDUCTION PATIENTS ONLY

Scheduling Your Appointment

By clicking "SUBMIT" below, you give us your permission to request, review and discuss your medical history and test results with your providers.