Self-Requesting Screening Mammogram

Thank you for scheduling a screening mammogram at Houston Methodist Breast Care Center at Sugar Land. As a last step, please complete this form if you do not have a doctor’s order.

• Your results will be sent to Houston Methodist Breast Surgery Partners at Sugar Land if you do not list an established doctor.
• This is for a screening mammogram only, not a diagnostic mammogram. If you have a breast mass, lump, pain, etc., please call 281.242.7465 to schedule a diagnostic mammogram.

 

*denotes required field

Patient's First Name * Patient's Last Name * Patient's Date of Birth * Email address * Phone * Please write the name of the doctor to receive your screening mammogram results. If you do not have a doctor, your results will be sent to Houston Methodist Breast Surgery Partners at Sugar Land. Doctor's First Name Doctor's Last Name

I agree that I have seen this doctor within the last year

True False

Patient Certification

Houston Methodist Breast Care Center at Sugar Land is authorized to accept self-requesting screening mammography without a doctor’s order if you answer “True” or “Not applicable” for the questions below. If you answer False to any of the following questions, you will need to obtain a physician order to schedule.

I am female age 40 or older *

True False

I have had no other screening mammograms performed in this calendar year *

True False

For Medicare/Medicaid, my last mammogram was more than 365 days ago *

True False Not Applicable

I do not have a mass or lump that I can feel *

True False

I do not have nipple discharge *

True False

I do not have skin lesions or cuts on my breasts *

True False

I have not had breast cancer in the past five years *

True False

By checking this box and providing my full name below, I authorize the release of all breast imaging and reports to Houston Methodist Breast Care Center at Sugar Land. Full Name/Signature *

Authentication *