Online Mammography Appointments

Online Mammography Appointments

Welcome to Holy Redeemer’s convenient online mammogram screening scheduling service. Please enter your information below if you qualify for online appointment scheduling; you can find the qualifying requirements listed on this page. All fields are required except for those noted as optional.

Date of Birth (enter as MM/DD/YYYY)*

Please remember, you can request an appointment online if you are 40 years of age or older.
First Name*
Middle Name
Last Name*
Gender*
Address 1*
Address 2
City*
State*
Zip Code*
Email Address*
Preferred Phone Number*
Can a message be left at the number provided?*


Physician Information

We will send the results of your mammogram to your referring physician. In addition, a prescription is required when scheduling your annual mammogram. Please fill out the below contact information for your referring and primary care physician(s):

Name of physician ordering the mammogram*:
Phone number of ordering physician*:
Name of primary care physician (Optional):
Phone number of primary care physician (Optional):

Insurance Information

Most insurance companies will cover your yearly routine mammogram screening. Please fill out your below insurance information for our records:

Name of insurance policy (i.e. Keystone, Personal Choice, Aetna, etc.)*:
Is the policy in your name or in another person's name?*


Please fill out the name and date of birth of the individual whose name is on the insurance policy.

Name:
Date of Birth (enter as MM/DD/YYYY):

Preferred Appointment Time

Preferred day of the week for appointment (check all that apply):






Preferred time of day for appointment (check all that apply):






Preferred Location (check all that apply):




Additional Options

Please note that these options are only available at our Southampton location. If you’d like to add one or all of these to your annual mammogram screening, please check the appropriate boxes.

Real-Time Read
Breast Tomosynthesis (commonly referred to as a 3D mammogram)
ABUS (Automated Breast Ultrasound System)