We are pleased to accommodate your request for an appointment online. Simply fill out the form and we will email you an appointment within 48 hours. Charlotte Radiology is concerned about the privacy of your personal and medical information. Our appointment scheduling forms are encrypted for complete security of any information submitted.
* Denotes required fields
Patient Information
First Name * : Middle Initial : Last Name * :
Name You Prefer to Be Addressed By :
Date of Birth (mm/dd/yy) * :
Email Address * :
Confirm Email Address :
Home Phone : Work Phone : Cell Phone :
Address * :
City * : State * : AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code * :
Account Number :
Physician Report Sent To * :
Insurance Provider * :
Clinical Information
Do you have any new breast lumps or problems with your breast? * Yes No
Do you have breast implants? * Yes No
Have you had a mammogram at a facility other than Charlotte Radiology? Yes No If yes, please bring to your mammogram appointment. Prior mammograms are needed for comparison to make the most accurate diagnosis.
Preferred Location
All of our locations offer digital mammography, the latest technology in breast cancer detection. Exams are performed by specialized technologists and read by sub-specialized physicians in the area of mammography.(hold down CTRL key to select multiple choices):
Ballantyne Gastonia Matthews Monroe Morehead Medical Plaza Northcross Pineville Randolph Rd. Rock Hill South Park University
Preferred Date and Time
First Available OR Month N/A January February March April May June July August September October November December Date N/A 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year N/A 2009 2010 2011
Use this section to select a specific day of the week and time of day preference:
Preferred Day of the Week : N/A Monday Tuesday Wednesday Thursday Friday Saturday
Preferred Time of Day : N/A Early morning (7:30am-9am) Late morning (9am-11am) Mid-day (11am-1pm) Early afternoon (1pm-3pm) Late afternoon (3pm-4:30pm)
Special Notes:
* Saturday appointments vary by facility. If you choose a Saturday appointment, the location and time requested may vary.
What prompted you to schedule your mammogram? (check all that apply) Physician Reminder letter/email Print Ad - newspaper/magazine Radio Ad Online Ad Facebook/Twitter E-mail Blast Friend/Family Member Event/Health Fair News story Other
Please click the Submit Button only once. You will receive your appointment confirmation via email within the 48 hours.
