Mammography Appointment Request

If you need assistance completing this form or would like to schedule your appointment by phone, please call 319-339-3948 from 8 a.m. to 5 p.m. weekdays.
Do you have an order for your exam?*  
Is 3D Imaging (Tomosynthesis) wanted for this exam?*
Please check with your insurance for coverage: Billing codes G0202 (screening) and 77063 (Add-on tomosynthesis code).
 


Are you having a problem with your breasts?*  
Do you have a history of breast cancer?*  
Have you breast fed within the last three months?*  
Do you have breast implants?
Do you have a DEXA order to accompany your mammogram?*
When was your last mammogram?*
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Where was your last mammogram done?
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Name of Ordering Provider
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