Support the Fight Against Breast Cancer!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:

* Required fields
First Name * M.I.
 Last Name *



Date of Birth (MM/DD/YYYY) * / /
Email *
Confirm Email *
Contact Phone # * - -
Alternate Phone - -
Address
City
State
 Zip Code    
Are you currently having any breast problems? (lumps, pain, discharge, etc.) *
Yes          No
If Yes Please Explain
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

 North Ankeny Medical Park
3625 N Ankeny Blvd, Suite H
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
What Prompted you to schedule your mammogram? (please mark all that apply.)
Physician Referral     TV     Radio     Newspaper     Friend or Relative     Internet    
Event In the Community     Magazine     Billboard     Community Greetings     Yellow Pages    
Other   
Special Requests or Comments: