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

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.

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.

By clicking the Submit button, you agree to the Houston Methodist Privacy Policy and Disclaimer.