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Screening Mammogram Appointment Request

We’re here to help you book a convenient appointment for your next screening (routine) mammogram. Complete this secure online form and we will contact you.

All Baptist Health breast imaging locations offer 3D Mammography exams.

If you need a diagnostic mammogram to investigate inconclusive or suspicious results from a screening mammogram, please call us at 904.202.2222.

By submitting this request form, you are authorizing Baptist to contact you using the methods you provide below.

Patient Information

First Name (required)^*

Last Name (required)^*

Email Address (required)^*

Primary Phone Number (required)^*

Primary Phone Type (required)^*

Gender(required)^* Gender at birth

Date of Birth (required)^*

Select your birth month from the dropdown, then enter your birth day, followed by your birth year.

Select a Month

Day in two digits

Year in four digits

E.g. January 01, 1990

What prompted you to request a screening mammogram today: (select all that apply)

Doctor recommended it
Family/friend recommended it or inspired me to take action
Reminder letter from Baptist
Reminder email from Baptist
Other

Do you have a primary care doctor? (required)^*

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