Watch for our next mobile bus, coming to the East Village Wal-Mart! • Mammograms should be scheduled once/year once you’re over 30 •

Medical Records Request Form

Please allow up to 48 hours after your exam has been completed before requesting records.

You may access your patient portal at any time:

Full Name

Birthday

Phone

Email Address

Home Address

If you need a copy of your report sent to your physician, please enter their full name and correct fax number

If additional imaging or follow up has been advised by your physician, please let us know where you want your images sent:

Home Address Facility

If you answered FACILITY above, please enter the name and address of the facility you would like them to be sent

We put patients first.

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