Patient Information

Would you like an confirmation of this screening request via email?  Yes No

Your Email

*Will you be using insurance?  Yes No

Primary Insurance

Who Is Your Referring Doctor?

*Practice Name

Please leave this field empty.

Need a Doctor? Click here.

Some General Questions

Do you have breast implants?  Yes No

Have you had a mammogram before?  Yes No

If yes, where?

Do You Qualify for a Screening Mammogram?  Yes No

You DO NOT qualify for a screening mammogram if you’ve had breast cancer or if you are experiencing any of the following: unilateral new pain, new discharge, lump(s), mass, density, new nipple inversion, or short term follow-up or any follow-up suggested by radiologist

Appointment Preferences

*Have you been to Wake Radiology before?  Yes No

What is your preferred location?

---WR North Hills Breast Center - 3D Available!WR Cary Breast Center - 3D Available!WR Chapel Hill - 3D Available!WR Fuquay-VarinaWR Garner - 3D Available!WR North RaleighWR Smithfield - 3D Available!WR West Raleigh Breast Imaging - 3D Available!WR Morrisville Women's ImagingWR Wake Forest Mammography - 3D Available!

Important Terms

I am requesting an appointment for a screening mammogram and understand that I will receive a confirmation of this request at the email address that is listed above. If I have not supplied an email address or if I don’t receive a reply, I understand that I can call WR Express Scheduling at 919-232-4700 and request an appointment. I verify that I am an established patient with the referring doctor that I have listed in this request.

 I agree to the above terms

By submitting the appointment request form, a member of our Scheduling team will contact you within 48 hours to set up your appointment at the specified date, time and location. If you contacted us on a weekend or holiday, please allow one additional business day. Email from Wake Radiology can be trapped by email filters. Please check your junk mail folder or adjust your span filters to allow mail from .