LACGH Mammography Screening Appointment Request

The LACGH Mammography Department is open Wednesday-Friday. We are closed Weekends and Stat holidays. Please answer these questions to request an Mammogram appointment. Our team will then contact you to offer a date/time for your test. If you are requesting a test for multiple persons, please fill out one request per person. Please note that the Ontario Breast Screening Program limits the testing of individuals to specific populations.

In order to book an appointment without a physician requisition, participants must be:

  • Between the ages of 50-75 years old
  • Have no previous history of breast cancer.

Patients with symptoms and concerns must see a physician for referral to a breast assessment center.

 

NEW LOCATION: The Mammography Department is now located at 310 Bridge St West, Unit G2 in the Lenadco Complex (the same location as the MRI and BMD suite). 

 

1. First Name of the person to be tested (as shown on health card): *

 

2. Last Name of the person to be tested (as shown on health card): *

 

3. Date of Birth (DD/MM/YYYY): *

 

4. Health Card # with version code (123456789-XX): For Military-please call the office to book an appointment (613-354-3301 ext 535) *

 

5. Gender (as shown on health card):?

 

6. Home Street Address: *

 

7. City: *

 

8. Postal Code (A2A 2A2) : *

 

9. Province: *

 

10. Preferred contact phone number with area code: *

 

11. If you would like to receive text or email reminders of your appointments, please enter your email and/or cell phone number below:

 

12. Family Doctor/Nurse Practitioner name and location: (i.e. Dr Roger Smith, Napanee) If you do not have a family doctor and are self-referring please leave this field blank.

 
Regarding the person requiring the Mammo test, have they / you:


 

13. Any previous history of Breast Cancer?

 

14. Have you had Mammogram before? *

 

15. Does the patient have breast implants?

 

16. Are you pregnant?

 

17. Are there any current symptoms or concerns?

 

18. Preferred time period for appointment (testing is available routinely Wednesday to Friday 8am to 2:45pm, excluding statutory holidays however, one Wednesday a month we do offer appointments until 530 pm). 
We will try to accommodate your preference.

 

19. Any other information we should know regarding this appointment booking?

 

We are committed to respecting your privacy rights as a guest to the LACGH Mammography Screening Centre.
 
Our practices are consistent with Ontario’s privacy legislation.  When you use this form, we collect only what is necessary to provide the health care needed for booking a Mammography appointment.  We take the necessary precautions to protect it from unauthorized access, linkage, disclosure or alteration.
 
For questions or comments regarding this privacy statement, please reach out privacy@lacgh.napanee.on.ca