/ Schedule a Mammogram

Mammography Annual Screenings

We welcome you to our online scheduling for screening mammography.

Please schedule your next screening mammography appointment using our form below. You will be contacted by one of our scheduling representatives to confirm your appointment within the next 24 hours. Our scheduling representatives will work with you to confirm and pre-register you for your visit. We look forward to your visit!

Our scheduling representatives are also available via telephone. You are welcome to call us at 843.402.5000 option 2 with any scheduling questions or requests.

Contact Information

First Name: * *

Last Name:* *

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

Social Security Number:

Address 1: * *

Address 2:

City: * *

State: * *

ZipCode: * *

Email Address: *

Phone Number *

Home Phone:

Cell Phone:

Alternate Phone:

Last Mammogram

I never had a mammography done.

Date of Last Mammogram(MM/DD/YYYY):* *

Location of Last Mammogram:*

Insurance Information

I do not have Insurance.

Primary Insurance

Insurance Company Name:* *

Policy/Member ID:* *

Group Number:* *

Subscriber Name:* *

Subscriber Date of Birth(MM/DD/YYYY):* *

Secondary Insurance

Insurance Company Name:

Policy/Member ID:

Group Number:

Subscriber Name:

Subscriber Date of Birth(MM/DD/YYYY):

Physician

You must bring a written order. If you do not have a written order, please request one from your physician. If you do not have a physician, please call (843) 402-2273 for a physician referral or call (843) 402-5000 option 2 with questions.

Ordering Physician Name: * *

Primary Physician Name:

Appointment Preference and Location

Appointment Location:

First Available

--Select a Preferred Day--

--Select a Preferred Time--

Comments:

Mammography Annual Screenings

Contact Information

Phone Number *

Last Mammogram

Insurance Information

Primary Insurance

Secondary Insurance

Physician

Appointment Preference and Location

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