Physician Office Breast Center Scheduling – Jefferson Regional

In order to process the appointment, please complete all of the information below. A coordinator will schedule an appointment as quickly as possible. Please ensure the accuracy of the information provided.

Ordering Physician(Required)

Full Name

Physician\Clinic Phone(Required)

Clinic Contact Name(Required)

Full Name

Patient Name(Required)

First Middle Last

Date of Birth(Required)

Primary Phone(Required)

Secondary Phone

Insurance

Insurance Policy Number

Authorization Number

Appointment Preference

Day Preference

No Preference

Monday

Tuesday

Wednesday

Thursday

Friday

Procedure (please select at least one)(Required)

Unlisted Procedure (please specify)

Diagnosis Code(Required)

Is this an annual mammogram appointment?

Yes

Has the patient had a mammogram in the last year?

Yes

Does patient have breast implants?

Yes

When was patient’s last mammogram?

Was their last mammogram abnormal?

Yes

Was the last mammogram performed at JRMC?

Yes

Please provide where the last mammogram was performed.

Diagnostic Mammogram requires proper indications and a signed physician order, including order for PRN ultrasound if needed. Prior images and reports are needed on hand for Diagnostic exams, follow up exams, additional views, breast ultrasounds, and mammotomes.

Ultrasound requires proper indications and a signed physician order, including order for PRN diagnostic mammogram if needed. Prior images and reports are needed on hand for Diagnostic exams, follow up exams, additional views, and mammotomes.

Is patient having any problems with breast or any concerns about anything with their breast?

Yes

Does the patient have a history of Breast Cancer?

Yes

Has patient received a COVID-19 Vaccination?

Yes

Unsure

Recommendations following vaccinations are to delay imaging 4-6 weeks following the second dose of a COVID-19 vaccination

Secure File Upload (Please upload any appropriate documents below)

Drop files here or

Max. file size: 50 MB, Max. files: 10.

A maximum of 10 files can be attached. Please submit only .PDF, .JPG, .TIF, or .DOC files. The total file size should not be greater than 50MB. If you exceed the file limitation, and need to submit additional files, use the "Additional File Upload" form.

Alternatively, you can fax documents associated to this patient to 8705416427 by using the fillable cover sheet below.

Breast Center Fax Cover Sheet Download

Jefferson Regional is committed to and has implemented many safeguards to ensure its devices, services, websites and data systems are compliant with the regulations and conditions set forth in the Health Insurance Portability and Availability Act of 1996 (HIPAA).

Phone

This field is for validation purposes and should be left unchanged.