Request a Mammogram Appointment

Thank you for requesting a mammogram at one of Northwestern Medicine Lake Forest Hospital's five locations.

Please complete the fields below and submit. Your request will go to a scheduler who will contact you by email or phone within one business day during regular business hours, Monday to Friday.

Please note: this appointment request is not for emergencies, same day or next day appointments. If you need an appointment within the next 48 hours, please contact us directly at 847.535.8000.

This appointment request form requires you to answer confidential health information that is needed to complete your request and shall be used only for the purpose of helping you secure an office visit. Your personal information will not be shared with any party outside of Northwestern Medicine Lake Forest Hospital.

*required information

First Name*

Last Name*

Address*

City*

State*

Zip Code*

Date of Birth*

Day Phone*

Email*

How do you prefer we contact you?*

Email
Phone

Who is your gynecologist and/or primary care physician?*

Are you scheduling a screening or diagnostic mammogram?*

Screening
Diagnostic
Other

If you are requesting a diagnostic mammogram, do you have a referral from your physician?

Yes
No

Have you had a mammogram at Northwestern Medicine Lake Forest Hospital before?*

Yes
No

Which time(s) of the day would you prefer your appointment?
(Check all that apply.)*

Morning (8:00 to 11:00 a.m.)
Noon (11:00 a.m. to 1:00 p.m.)
Afternoon (1:00 to 4:00 p.m.)
Evening (4:00 to 6:00 p.m.), when available

Which day(s) of the week would you prefer your appointment?
(Check all that apply.)*

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday (when available)

Please provide any additional details about your request.

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