Mammogram Questionnaire

Please complete this questionnaire before booking your private screening mammogram. This service is for screening only.

Do not use this service if you have breast symptoms such as a lump, nipple discharge, skin changes, nipple changes, breast pain, or a lump in the armpit.

Patient details

First name * Last name * Date of birth * Gender *Email * Phone number *

Screening criteria

I confirm that I am aged 40 or over.

I confirm that I am requesting this mammogram for screening only.

I confirm that I do not have breast symptoms such as a lump, nipple discharge, nipple changes, skin changes, breast pain, new asymmetry, or a lump in the armpit.

Are you pregnant or could you be pregnant? *Are you currently breastfeeding? *Do you have breast implants? *When was your last mammogram? Please add any relevant background information

Declaration

I confirm that the information I have provided is accurate.

I understand that my scan request may still be reviewed before the appointment is confirmed.

I consent to being contacted about this scan request.

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Mammogram Questionnaire

Mammogram Questionnaire

Patient details

Screening criteria

Declaration