Schedule a Mammogram Appointment To schedule an appointment for a screening mammogram at one of our four convenient locations please complete the form below. The information from this form may be sent to the scheduling fax number at (919) 784-3094 and a representative will contact you to schedule your appointment. We will contact you with your registration and appointment information. Please note: Diagnostic mammograms require a physician's order. Click here for more information on screening vs. diagnostic mammograms.
* Indicates required information
First Name *
Middle Name
Last Name *
Street Address 1 *
Street Address 2
City *
State *	AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY
Zip *
Date of Birth *	(mm/dd/yyyy)
Email Address
Day Phone *
Evening Phone
Cell Phone
Physician Name *
Primary Insurance Company *
Secondary Insurance Company
Self Pay *	Yes No
Preferred day for screening mammogram appointment
First Choice	Monday Tuesday Wednesday Thursday Friday
Second Choice	Monday Tuesday Wednesday Thursday Friday
Third Choice	Monday Tuesday Wednesday Thursday Friday
Preferred time of day for screening mammogram appointment
First Choice	Morning Mid-day Afternoon
Second Choice	Morning Mid-day Afternoon
Preferred location for screening mammogram appointment *	Raleigh Cary Wakefield Holly Springs Knightdale
Have you had prior mammograms at Rex? *	Yes No
Would you like to be called to confirm your appointment? *	Yes No
Would you like to receive an email to confirm your appointment? *	Yes No
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