Online Scheduling for Mammography Appointments

Thank you for choosing CHN. We are proud to offer fully digital mammography providing detailed images and fast results.

For women age 40 and over, an annual mammogram is the most important way to detect breast cancer in its earliest stages. If your last mammogram was not performed at CHN, please include information on your previous mammogram location. We will attempt to retrieve your records for comparative purposes.

- NOTICE -
If you are currently having any breast problems (lumps, pain, discharge), please see your Healthcare Provider FIRST.
For a list of CHN Providers please CLICK HERE.

Prep for Mammogram:

First Name:
M.I.:
Last Name:
Date of Birth (MM/DD/YYYY):
Email Address:
Phone #:
Cell Phone #:
Address:
City:
State:
Zip:
Are you currently having any breast problems at this time? (lumps, pain, discharge, etc.)
No Yes If "Yes" you must see your Provider FIRST!
Have you had breast cancer within the last five (5) years?
No Yes  
Do you have breast implants?
No Yes  
Is this your first mammogram?
No Yes  
If "No" Has it been at least 1 year since your last Mamogram: Yes No
Please provide information on your previous mammogram location.
Practice Name:
City/State:
Approx. Date:
Physician that will receive results:
Which of our locations do you prefer to have your mammogram?
Berlin Memorial Hospital CHN Medical Center - Wautoma
Preferred Date(s):
1st Choice:
Pick a date
2nd Choice:
Pick a date
Preferred Time of Day (M-F):
10-12pm 12-2pm 2-6pm
or Saturday Appointments Available:
What prompted you to schedule your mammogram? (please mark all that apply)
TV Radio Newspaper
Event  Billboard Internet
Reminder card Mailer Contact from CHN  Annual Appointment
Other (indicate)
Comments or special considerations:
Our staff will contact you shortly to confirm your appointment.