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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 * 
Zip * 
Date of Birth *   Calendar (mm/dd/yyyy)
Sex * 

Email Address 
Day Phone * 
Evening Phone 
Cell Phone 
Physician Name * 
Primary Insurance Company * 
Policy Holder's name * 
Relation to Policy Holder * 
Policy Holder's Birth Date *   Calendar (mm/dd/yyyy)
Sex of Policy Holder * 

Policy Number * 
Group Number * 
Secondary Insurance Company 
Policy Holder's name 
Relation to Policy Holder 
Policy Holder's Birth Date   Calendar (mm/dd/yyyy)
Sex of Policy Holder * 

Policy Number 
Group Number 
Self Pay * 

Do you have a history of Breast Cancer? * 

Are you currently having any problems with your breast? * 

Would you like a standard Digital mammogram or 3D memmorgram? (3D mammography may result in an additional out-of-pocket charge and is only offered at the Raleigh location). * 

Preferred day for screening mammogram appointment 
First Choice 
Second Choice 
Third Choice 
Preferred time of day for screening mammogram appointment 
First Choice 
Second Choice 
Preferred location for screening mammogram appointment * 
Have you had prior mammograms at Rex? * 
Would you like to be called to confirm your appointment? *