SCREENING 3D MAMMOGRAMS Appointment Request Form
Welcome to our imaging center, SIERRA VISTA DIAGNOSTICS!!

Screening mammography saves lives...with that in mind, the online request form was designed to make scheduling of your screening 3D mammogram as streamlined as possible:)

The online request form is intended to be utilized for screening mammograms only. If you are currently experiencing a new breast problem/symptom, or to schedule diagnostic mammography, breast ultrasound, breast MRI, breast biopsy or any other imaging examination, please call our imaging center schedulers directly at (520) 459-5227.

***YOU SHOULD EXPECT A PHONE CALL RESPONSE TO YOUR ONLINE REQUEST WITHIN THE NEXT 48 HOURS***

"SIERRA VISTA DIAGNOSTICS. SUPERIOR IMAGING, SUPERIOR CARE" -- call us at (520) 459-5227
PERSONAL INFORMATION
First Name
Your answer
Last Name
Your answer
Date of birth
Date in mm/dd/yyyy or mm-dd-yyyy formats
Your answer
PRIOR MAMMOGRAMS
When was your last mammogram performed?
Where were your most recent prior mammograms performed? (check all that apply)
Required
If you have ever had prior mammograms performed at a facility (or facilities) in Tucson, please tell us where... (check all that apply)
If your prior mammograms were performed at a facility somewhere other than the sites listed above, please tell us where...(please answer as completely as possible--include name of facility, city, state)
Your answer
APPOINTMENT PREFERENCE
Please provide your preference for an appointment (at least one week from today). We will do our best to accomodate your request :)

IF YOU PREFER TO SCHEDULE AN APPOINTMENT TO BE PERFORMED THIS WEEK, PLEASE CALL (520) 459-5227 EXT 4504

Preferred days:
Choose at least one. You may select more than one.
Required
Preferred time:
Select only one of following 3 options
Required
CONTACT & ADDITIONAL INFORMATION
What is the best contact number(s) for you?
7 digit without area code, or 10 digit with area code. May use '-' '.' or '()'
Your answer
Best time to call:
Your email
Your answer
Insurance
Your answer
Your doctor's name
Your answer
Reason for exam:
**PLEASE NOTE: We are required to obtain an order from your doctor before we can finalize scheduling for your screening mammogram. Please tell us your preference for attempting to obtain the order...
CAPATCHA QUESTION:
What is 2 + 2
Your answer
"SIERRA VISTA DIAGNOSTICS. SUPERIOR IMAGING, SUPERIOR CARE"
Thank you for choosing SIERRA VISTA DIAGNOSTICS!!
***YOU SHOULD EXPECT A PHONE CALL RESPONSE TO YOUR REQUEST WITHIN THE NEXT 48 HOURS***
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