Request an Appointment

Please fill in the following information and click "submit" to request an appointment. If you do not hear from someone within 3 to 4 business days or 5 days ahead of the event you selected, please call 315-464-2588.

Please verify all contact information is correct and look for a phone call from our registration staff. If you do not answer, we will leave a voice message with a direct call back number.

We are only able to do routine screening mammograms on the mobile unit. If you are having problems with your breast (lumps found, nipple discharge), you should contact your physician. Those with a family history of breast cancer can still get a screening mammogram.

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Patient Information

*First Name :

*Last Name :

Middle Initial :

*Street Address :

*City :

*State :

*Zip :

*Date of Birth (mm/dd/yyyy):

Email (user@place.com):

*Phone Number :

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*Name of your primary care provider and/or gynecologist (if no PCP/GYN enter "NONE") :

*Insurance Plan (if no insurance, enter "NONE") :

*Preferred language :

*Interpreter needed ? Yes No

*Is this for a routine mammogram ? Yes No

If no, indicate problem :

*Have you had a mammogram before ? Yes No

If yes, where and when ?

*Do you need assistance in walking or climbing stairs ? Yes No

Other Information

*How did you hear about us? Please check all that apply :

TV ad

Radio ad

Social Media

Repeat Patient

Flier

Friend

Host site

My Doctor

Other Source

Questions

Let us know if you have questions about your eligibility for a screening mammogram on the mobile unit :

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