Mammography Screening Form

Please complete the form below to request a screening mammography. Click on Submit Appointment when finished. (Note: You will not immediately receive an email response). We value your privacy. Personal information will be used only to schedule an appointment. If you have questions or would like to speak to a Scheduling Representative, please call 484-628-8611.

Guidelines for Scheduling a Screening Mammography Online:

  • No signs or symptoms of breast complaints
  • Not pregnant
  • Have not breastfed within the past six months
  • Annual after age 40 (11 full months must have passed following the month in which the last screening mammogram was performed.)

Helpful Hints:

  • Reduce caffeine intake 3-5 days prior if breast tenderness is a problem
  • Schedule your appointment as closely after your menstrual period as possible, as this helps minimize discomfort due to breast tenderness.
  • Do not wear powder, creams, lotions, or deodorant on day of appointment

An asterisk (*) indicates a required field.

Complete the information below:
*
*
*
MM/DD/YYYY
*
*
*
*
*
*
*
*