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Request a Mammogram

Please complete this form or call 734-712-1313 to schedule a routine screening mammography exam . Please consult with your physician office to determine whether a screening or diagnostic mammogram is needed. If you are in need of urgent mammography services, please call 734-712-1313 or 1-800-396-1313 (toll free)

* Indicates required information
Patient's Last Name * 
Patient's First Name * 
Patient's Middle Initial 
SJMHS ID # (found on your SJMHS ID card) 
Date of Birth *  (mm/dd/yyyy)
Street * 
City * 
State * 
Zip * 
Email Address * 
Home Phone Number * 
Alternate Phone Number 
Type of Insurance (Examples: Blue Cross, Medicare, Self-pay, etc.) * 
Insurance Card Information: List all detail found on your insurance card including the name of the policy holder * 
Physician ordering this test (Please include first and last name) * 
Physician's Address * 
Primary Care Physician * 
Physician's Address * 
Did you have your last mammogram at a SJMHS location? * 

Date of Last Mammogram  (mm/dd/yyyy)
Preferred Location * 

Preferred Day(s) * 

Preferred Time * 
Have you noticed any changes in your breasts? * 

Do you have a history of breast cancer? * 

Do you need a wheelchair? * 

Do you have breast implants? * 

Are you pregnant? * 

Are you breast feeding? * 

Authentication * 

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You can expect to receive a reply from Saint Joseph Mercy Health System Central Scheduling via email or phone within two business days.  If you do not receive a response, please call (toll free) 1-800-396-1313.
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St. Joseph Mercy Ann Arbor | 5301 McAuley Drive, Ypsilanti, MI 48197 | 734-712-3456