request a mammogram appointment

Time for your annual mammogram? Request an appointment time by filling out the email form below! A Bon Secours representative will respond to your request at the phone number or email you provide within the next 2-4 business days to confirm your appointment.

If you'd rather call you can reach us directly at (757) 398-2316 or toll-free at 1 (866) 878-9488.

*Appointments are available on selected Saturdays at Bon Secours Harbourview and Bon Secours DePaul.

This form is for a routine screening mammogram. If you meet any of the following criteria, please consult with your physician directly to set an order for an exam with one of our breast centers:

  • Have a serious breast problem. (Click here for a full list of symptoms.)
  • Are under the age of 35.
  • Have a personal history of breast cancer.
  • Are back for the first mammogram after having breast surgery for any abnormal condition.
  • Are having a follow-up mammogram less than 12 months from your most recent normal mammogram.

If none of these conditions apply to you please fill out the form below.

Full Name: *
Date of Birth: *
Email Address: *
Phone Number: *
Insurance: *
Physician Name:

Please choose your preferred location from the drop-down list below.

Note the date and time that best suit your schedule. Please request a date at least two weeks in advance of today, in case we need to locate additional information or previous mammogram films. Appointments are available at all locations Monday through Friday.

Block of Time Availability (if preferred):

Please indicate in this box if you would like to request an appointment for a 3-D mammogram.

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