Cchwfe Mammogram Signup Form for February 2025

Mammogram Appointment Request Form

Fill the form below and we will get back soon to you for more updates and plan your appointment.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home phone number :
Mobile phone number :
Work phone number :
Date of Birth

DayMonthYear
Gender
Emergency contact name

First NameLast Name
Emergency Contact Phone Number
Emergency Contact Name
DOB
Age
Race
SSN:
Place of Employment
Insurance Name
Insurance ID#
Insurance Group#
Insurance Phone#
Email
example@example.com
Implants

YesNo
Breast Problems?

YesNo
Are you pregnant?

YesNo
Date of last Mammogram
Location of Last Mammogram
Does your family have a history of Breast Cancer?
Physican name
Physican Phone Number
Thank you for reserving your spot to receive your yearly mammogram. Please read the information below provided by Piedmont Augusta to ensure you come prepared for your appointment.

Thank You, CCHWFE
Annual screening mammograms will be offered to women age 40 and over. Insurance will be filed so bring your insurance card and photo ID to your appointment. The mammogram takes about 10 minutes and results will be provided to you and your doctor within a week.

YOUR TIME IS VALUABLE, YOUR LIFE IS PRICELESS

A MAMMOGRAM CAN SAVE YOUR LIFE
Piedmont AUGUSTA

Breast Health Imaging Mobile Mammography

Piedmont Augusta Breast Health Imaging Mobile Mammography looks forward to returning to your facility.

We would like to remind you of the following:

Only screening mammograms are done on the mobile van.

• Appointments are made every 15 minutes.
• Patient registration forms must be fully completed and returned to our office at least two weeks prior to our visit.
• The appointment schedule must be completed with consecutive times no gaps between appointments (if you are unable to fill the entire day, please notify us and we can work with you to schedule a half day or condensed schedule).
• All participants must have their physician listed on their registration form in order for us to do the mammogram (PA's and NPs excluded).
• Please have each participant bring a copy of their insurance card and a valid picture ID at the time of the mammogram.
• For information on our patient assistance program, please contact us.
• Billing will come from Piedmont Augusta (technical fee) and Brown Radiology (reading fee) It is the participant's responsibility to check with their insurance to verify benefits and coverage.
We look forward to bringing this life saving service to your area. We appreciate the opportunity to provide your staff with excellent breast health care. Remember mammograms are recommended every one year by the American Cancer Society.

Mobiledate:____________________________________________

Return completed forms by :_________________________________________

If you have any questions, please call our mobile office at (706) 774-4149.

Martha Jordon, RTRM

Lead Mammography Technologist

Breast Health Imaging Mobile Mammography
Preferred Appointment Date *
Should be Empty:

Mammogram Appointment Request Form