Mammography Annual Screenings

Mammography Annual Screenings


We welcome you to our online scheduling for screening mammography.

Please schedule your next screening mammography appointment using our form below. You will be contacted by one of our scheduling representatives to confirm your appointment within the next 24 hours. Our scheduling representatives will work with you to confirm and pre-register you for your visit. We look forward to your visit!

Our scheduling representatives are also available via telephone. You are welcome to call us at 843.402.5000 option 2 with any scheduling questions or requests.

Contact Information

First Name:*  
Last Name:*  
Date of Birth(MM/DD/YYYY):*  
Social Security Number:
Address 1: *  
Address 2:
City: *  
State: *  
ZipCode: *  
Email Address:  

Phone Number

Home Phone:
Cell Phone:
Alternate Phone:

Last Mammogram

Date of Last Mammogram(MM/DD/YYYY):*  
Location of Last Mammogram:*

Insurance Information

Primary Insurance
Insurance Company Name:*  
Policy/Member ID:*  
Group Number:*  
Subscriber Name:*  
Subscriber Date of Birth(MM/DD/YYYY):*  
Secondary Insurance
Insurance Company Name:
Policy/Member ID:
Group Number:
Subscriber Name:
Subscriber Date of Birth(MM/DD/YYYY):

Physician

Ordering Physician Name:
Primary Physician Name:

Appointment Preference and Location

Appointment Location:
--Please Select a Location--
--Select a Preferred Day--
--Select a Preferred Time--

Comments:

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