Request A Mammogram Appointment

Request an Appointment

  • Do you have an order from your healthcare provider?
    Do you have an order from your healthcare provider?

  • A signed physician's order is required to schedule an appointment.

    Please ensure you have a signed physician’s order to proceed with the Request An Appointment Form

  • Your Information

  • Your name Your name *
  • Your date of birth Your date of birth * / /

  • Your Contact Information

  • Primary phone number Primary phone number * - -
  • Alternate phone number Alternate phone number - -

  • 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 you would like to be seen Date you would like to be seen / /
  • Time you would like to be seen *
    Time you would like to be seen
  • Type of study/modality (select one or more)

    PLEASE NOTE: Not all imaging services are available at each location. To determine if a specific imaging procedure or study is available at the location of your choice, please visit the corresponding service or location page. *
    Type of study/modality (select one or more)

    PLEASE NOTE: Not all imaging services are available at each location. To determine if a specific imaging procedure or study is available at the location of your choice, please visit the corresponding service or location page.

  • Additional Information

  • Who is your referring physician? Who is your referring physician? *

  • PLEASE NOTE:

  • If you elected to be contacted by email, please note that all correspondence from Tricounty Radiology 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 Tricounty Radiology will be encrypted, and you will need to log into a secure portal to retrieve your messages.
  • Tricounty Radiology 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 Tricounty Radiology to acquire certain data required to determine the scheduling necessities for the respective imaging exam you have selected on this request form. *
    Tricounty Radiology 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 Tricounty Radiology to acquire certain data required to determine the scheduling necessities for the respective imaging exam you have selected on this request form.

  • *
    In the number 94847, what is the 5th digit?