Mammogram Request Form

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 Harbour View 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.
  • 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.