I’m An Early Detection Champion – Request an Appointment

First Name*

Last Name*

Email*

Repeat Email*

Please remind me to schedule my appointment on*

Check all that apply:

I am an Early Detection Champion

I pledge to have my mammogram annually (40 and older)

I pledge to remind the women I love to schedule their mammogram

I am a survivor

I am inspired by someone that was affected by breast cancer

I am over age 13*

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Patient Date Of Birth *
Birth Day12345678910111213141516171819202122232425262728293031 Birth MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Birth Year1917191819191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092011201220132014201520162017

Patient Status (Required)New PatientExisting Patient

For mammogram appointments only – Has it been 4-6 weeks since you were fully vaccinated?
YesNo

-- Image Study Needed --Mammography

-- Location Preference --Amherst, NYHamburg, NYLancaster, NYWilliamsville, NYMobile Mammography Unit

Windsong staff will contact you to set up your appointment
after you submit your request with preferred dates and times.
Please wait for confirmation.

Preferred Day and Time

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