Mammography Online Appointment Form | Baptist Health South Florida
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Mammography Form

Request An Appointment

Thank you for requesting an appointment online for your mammogram. A scheduling assistant will respond via e-mail or telephone within 48 hours (except on weekends and on holidays).

If you prefer to make an appointment by phone, please call 786-573-6000. A physician's prescription is required for your appointment.

Before you submit a request for an appointment via our website, we are required by federal law to provide you with Baptist Health's Notice of Privacy Practices for your review. We respect your privacy, and all information is encrypted for your protection.

I agree with terms for online appointments  
I acknowledge receipt of the Notice of Privacy Practices.  

Mammogram Information
Doctor and diagnosis  
What is the name of the doctor who ordered the mammogram?
Phone Number
What is the diagnosis?

(If you don't have a doctor, click here for a Physician Referral)
Is your appointment for
(if you have no symptoms and no family history of breast cancer)

(if you have breast implants, a family or personal history of breast cancer, or you have a lump, discharge, calcification, pain or other condition that needs to be evaluated)
Does your prescription/order state "Breast Ultrasound", or "Breast Ultrasound if needed"?
Have you had a mammogram before?  
If Yes, where?
Appointment Information
We would like to schedule your mammogram at a location and time that is most convenient for you, if possible.
What is your preferred location?
On what day of the week would you prefer your appointment? Not all sites offer evening or Saturday appointments.
What time of the day is best for you?
Upload a copy or a picture of your doctor's prescription
.jpeg, .jpg, .gif, .png, .tiff
Personal Information
First Name   Your name and phone number are essential so that we may contact you to confirm your appointment.
Middle Name
Last Name  
Birth date (mm/dd/yyyy format)      
Social Security Number   (e.g. 123-45-6789)
Contact Information
Zip Code  
Best way to contact you regarding your appointment (check all that apply, at least one is required)  
It is important to include at least your telephone number, but please fill in all fields, if applicable.
The Scheduling Call Center will contact you in the manner you prefer to confirm your appointment.
However, you will be contacted via telephone by the Pre-Registration department.
Is there a telephone number where we may leave a detailed message regarding your registration/appointment?
Detailed Contact Phone  
Primary Insurance Information
Insurance Company Name
Policy Number
Group Number
Pre-certification or Benefits Phone Number(s)
Secondary Insurance Information
Insurance Company Name
Policy Number
Group Number
Pre-certification or Benefits Phone Number(s)
Email Notification
Please provide an email address(Confirmation of receipt will be sent to this address.)    

Last Updated: 09/17/2018 Time 03:24 PM