Screening Mammography Scheduling Request Form

Thank you for choosing Iowa Radiology. In keeping with our commitment to quality, we were one of the first facilities in Iowa to offer fully digital mammography. Digital mammography is the gold standard. It is more detailed than analog film images, especially for those patients under the age of 52 and for those who have dense breast tissue. It also provides improved images for patients with breast implants.

For women age 40 and over, an annual mammogram is the most important way to detect breast cancer in its earliest stages. If your last mammogram was not performed at Iowa Radiology, please include information on your previous mammogram location. We will attempt to retrieve your records for comparative purposes.

Prep for Mammogram:

• Do not use deodorant or perfume
• Plan for a 30-minute appointment
• Review the American Cancer Society's Guidelines for early detection of cancer.
  

* Required fields

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First Name *	M.I.	Last Name *
Date of Birth (MM/DD/YYYY) *	/ /
Email *
Contact Phone # *	- -
Alternate Phone	- -
Address
City
State		Zip Code
Are you currently having any breast problems at this time? (lumps, pain, discharge, etc.) * Yes          No
Have you had breast cancer within the last five (5) years? Yes          No
Do you have breast implants? Yes          No
Is this your first mammogram? * Yes          No	If "No",* where was your last mammogram performed? Clinic/practice name:       City/State: Approx. Date:
Referring Physician that will receive report *
Which facility do you prefer?
Clive      12368 Stratford Dr, Ste 350      Clive, IA  50325	Downtown      1221 Pleasant St, Ste 350      Des Moines, IA  50309	Ankeny          1105 N Ankeny Blvd, Ste 200          Ankeny, IA  50023
Preferred Date (MM/DD/YYYY)
Preferred Day of the Week Mon     Tue     Wed     Thu     Fri     Sat 8-12 (1st Saturday of the month--Clive; 3rd Saturday of the month--Ankeny)
Preferred Time of Day 8 - 10     10 - 12     12 - 2     2 - 5
How did you hear about Iowa Radiology? (Please mark all that apply.) My Doctor     Community Event (Kelly Corrigan)     Race for the Cure     Television     Newspaper     Magazine     Radio     Yellow Pages     Friend/Family
Special Requests or Comments: