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Schedule Your Mammogram
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- Breast Imaging Center
- Breast Ultrasound Imaging
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Schedule a Screening Mammogram

Comments
This field is for validation purposes and should be left unchanged.
To schedule your 3D screening mammogram at The Breast Center at VRI, simply review the screening questions. The VRI scheduling department will call you to finalize your appointment details.

The next few questions will determine if you qualify for a screening mammogram.
Are you 40 or older?
- Yes
- No

Have you had a mammogram within the last 12 months?
- Yes
- No

Do you currently have any breast concerns, including any lumps, pain, drainage, or sensitivity?
- Yes
- No

Patient Information
First Name*
Middle Name (optional)
Last Name*
Date of Birth*
MM slash DD slash YYYY
Email*
Best Phone Number*
Alternate Phone Number
Address
Street Address Address Line 2 City State ZIP Code

Your Referring Doctor
Please help us and enter your referring doctor's name and practice or specify that you do not have a referring doctor.
Select One:*
- My referring doctor information is below.
- I do not have a referring doctor.
Doctor's First Name
Doctor's Last Name*
Practice Name
Insurance Information
If you are using insurance, please provide the insurance company.
Insurance Company
General
Date of Last Mammogram
MM slash DD slash YYYY
- This is my first mammogram
Are you currently experiencing any breast concerns?*
- Yes
- No
Do you have a personal history of breast cancer?*
- Yes
- No
Do you have breast implants?*
- Yes
- No
Appointment Details
Please indicate your preferred day and time frame below. Our scheduling staff will review this information to find the most appropriate appointment time to best fit for your schedule.
Preferred Date (First Choice)*
MM slash DD slash YYYY
Preferred Time (First Choice)*
Preferred Date (Second Choice)
MM slash DD slash YYYY
Preferred Time (Second Choice)
Preferred Date (Third Choice)
MM slash DD slash YYYY
Preferred Time (Third Choice)
Where was your last mammogram performed?*
- Valley Regional Imaging
- I don't know
- This is my first mammogram
Preferred Method of Contact to Schedule Your Appointment*
- Phone
- Email
Comments/Questions:
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TEL: (910) 221-2500

FAX: (910) 221-2468

3186 Village Drive Ste 200
Fayetteville, NC 28304

Hours of Operation:
Monday - Friday: 7am-5pm
Saturday: 8am-12pm (Screening Mammograms only)
Sunday: Closed

Services Offered:
3D Mammography, Breast Ultrasound

info@valleyregionalimaging.com

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Call Us: (910) 221-2500