Screening Mammogram Request

Email appointment requests can be made for screening mammograms only. If you are having any problems with your breasts or if you have or have had any previous surgeries or implants, you will need to call (206) 248-8900 to schedule your appointment.

Important Notice:
The email requests below are not confidential or secure. If you are concerned about the privacy of your information, please call Highline Medical Imagining at (206) 248- 8900 directly to request an appointment.

Request Form
* First Name:
* Last Name:
Middle Initial:
* Date of Birth:	Format: mm/dd/yyyy
* Primary Phone:
Alternate Phone:
* Email:
* Confirm Email:
Preferred Contact Method: Phone Email
* Primary Care Physician:
First Name
Last Name
Are you a new patient at Highline Diagnostics at 160th? Yes No
If yes, where did you have your previous mammogram?:
Date of Last Mammogram:
	Format: mm/dd/yyy
Who is the appointment for? Me Someone Else
Your Insurance:	No Insurance/Not Listed Aetna ChoiceCare Cigna Community Health Plan of Washington ** DSHS First Choice Health Network First Health/Conventry Great West Healthcare Group Health ** Interplan Labor and Industries Medicare and Railroad Medicare Molina Premera Blue Cross Private Healthcare Systems/Multiplan Puget Sound Health Partners Regence BlueShield Secure Horizons/AARP Self-Insured Administrators Uniform Medical Plan United Healthcare/PacifiCare Zenith Administrators
* Options For Scheduling Appointment: First Available Appointment Schedule an appointment for a specific day of the week
* Desired Appointment Time: Early morning (before 10am) Late morning (10am - noon) Early afternoon (noon - 2pm) Late afternoon (2-5pm)