Screening Mammogram Request Form

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-DOCS.

Locations and Hours
Plainfield (1100 Southfield Drive) – weekdays from 8:30 a.m. to 4 p.m.
Danville (1000 E. Main Street) – weekdays from 7 a.m. to 6 p.m.
Name
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Email
Telephone
  
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What is your date of birth?
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Daytime Phone Number
(If we get your voice mail, we will leave a message. Staff will make two more attempts to reach you.)
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Select a location to have your mammogram.
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Provide your doctor's first and last name so we can send your results within 48 hours.
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Do you have preferences for day or time of your appointment (morning, evening, day of week, etc.)?
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Have you had a mammogram with us before?
If you selected "No," have you had a mammogram elsewhere? If so, please list the facility.
Any additional comments?

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© 2014 Hendricks Regional Health. All Rights Reserved.
Hendricks Regional Health is a hospital system with medical facilities and a physician group serving residents of Hendricks County in suburban Indianapolis, Indiana (IN), including the towns of Avon, Bainbridge, Brownsburg, Danville, Greencastle, Lizton, Monrovia and Plainfield.
1000 East Main Street Danville, Indiana 46122 Phone: (317) 745-4451
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