Mammogram Appointment Request

Please complete the following information and a member of the Fort HealthCare Radiology staff will call you back to set up the exact date and time of your appointment. Your information is confidential.

* Required Information

Contact Information
Name*: 
Age*: 

Daytime Phone*: 
Evening Phone*: 
E-mail*: 
 
Promo Code: 

When is the best time for a Radiology representative to contact you by phone?*
   


Mammogram History
When was the last time you had a mammogram?*

What was the result of your last mammogram?




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611 Sherman Avenue East, Fort Atkinson, WI 53538 | (920) 568-5000