Request A Mammogram Appointment

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Do you have a Physician's Order? If yes, please proceed. If not, please contact your referring physician to obtain an order.

We accept all physician-signed orders, even if they are on a hospital order form or prescription pad.
Your name Your name * First Last
Your date of birth: Your date of birth: * / MM / DD YYYY

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Street Address
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ZIP
Are you and existing patient?

Are you and existing patient? Yes No
If you elected to be contacted by email, please note that all correspondence from Durham Diagnostic Imaging will be encrypted, and you will need to log into a secure portal to retrieve your messages. *

If you elected to be contacted by email, please note that all correspondence from Durham Diagnostic Imaging will be encrypted, and you will need to log into a secure portal to retrieve your messages. I agree
Your email address: *

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Primary phone number Primary phone number - ### - ### ####
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When was your last screening mammogram performed? When was your last screening mammogram performed? / MM / DD YYYY

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Appointment Details

What day and time would you like your appointment? We will do our best to find a time that works for you, but cannot guarantee the time you have requested.
Date Date / MM / DD YYYY
What time? *

What time? Anytime Morning Afternoon
Preferred location: *
Are you interested in 3D mammography?
Additional Information
Mammograms are one of the best ways to screen for and diagnose breast cancer. At Durham Diagnostic Imaging, we offer the latest imaging technology, such as 3-D mammography, to help detect even the smallest abnormalities. We also believe in making quality healthcare accessible.
Durham Diagnostic Imaging takes the security and privacy of protected health information very seriously. We have implemented technical, administrative, and physical safeguards, which are designed to protect your information from unauthorized use and access. These safeguards are intended to ensure that our system is secure and that it meets our obligations under the HIPAA Security Standards Final Rule, as well as CCHIT Meaningful Use Security Requirements to specifically protect all electronic health information created or maintained by our certified Electronic Health Record technology. By providing your information and consent, you are authorizing Durham Diagnostic Imaging to acquire certain data required to determine the scheduling necessities for the respective imaging exam you have selected on this request form. *

Durham Diagnostic Imaging takes the security and privacy of protected health information very seriously. We have implemented technical, administrative, and physical safeguards, which are designed to protect your information from unauthorized use and access. These safeguards are intended to ensure that our system is secure and that it meets our obligations under the HIPAA Security Standards Final Rule, as well as CCHIT Meaningful Use Security Requirements to specifically protect all electronic health information created or maintained by our certified Electronic Health Record technology. By providing your information and consent, you are authorizing Durham Diagnostic Imaging to acquire certain data required to determine the scheduling necessities for the respective imaging exam you have selected on this request form. I agree
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Request A Mammogram Appointment

Request A Mammogram Appointment

There was a problem with your submission.

Do you have a Physician's Order? If yes, please proceed. If not, please contact your referring physician to obtain an order.

Appointment Details

Additional Information

Mammograms are one of the best ways to screen for and diagnose breast cancer. At Durham Diagnostic Imaging, we offer the latest imaging technology, such as 3-D mammography, to help detect even the smallest abnormalities. We also believe in making quality healthcare accessible.