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Mammogram Request Form

NEW FOR 2024! Do you have a MyChart account? You can now self-schedule a screening mammogram directly in MyChart. Request a MyChart account today.

Who Should Get a Screening Mammogram?
The American Cancer Society recommends that women age 40 and older have a screening mammogram every year for as long as they are in good health (and have no signs or symptoms of breast cancer). A doctor's order is not required to schedule.

If you are experiencing breast pain, a lump or skin thickening, nipple discharge or a change in the size or shape of your breast, we recommend that you first contact your doctor, so you can be referred for a diagnostic mammogram or other appropriate tests. If you do not have a doctor, call our physician referral line at (317) 745-4451.

Your Basic Information

Name*

Date of Birth*

Daytime Phone Number*

(If we get your voice mail, we will leave a message. Staff will make two more attempts to reach you.)

Mammogram Request Form

Your Basic Information

Schedule Your Screening