MGH REVERE HEALTHCARE CENTER
Screening Mammogram Appointment Request Form

MGH Revere HealthCare Center
300 Ocean Avenue
Revere, MA 02151

Use this secure form to submit a request for a screening mammogram appointment.
We will contact you to confirm your appointment.

For questions or help with this form please call 781-485-6180

Mass General Imaging - Revere
PART A
Mass General MRN#
PART B ( Skip part B if you already have an MRN Number )
Date of birth:
Home address:
Insurance carrier:
PART C
PLEASE NOTE: This form only generates a request; someone will contact you to schedule your appointment.
Phone:
Email address:

  • MGH Revere HealthCare Center now offers 3D mammography (tomosynthesis), a new technology pioneered
    at Mass General that promises better breast-cancer detection and fewer callbacks. Tomosynthesis is performed
    at the same time as a regular mammogram.

Select your exam preference:
3D Mammogram (Tomosynthesis) 2D Mammogram (Conventional)
Preferred appointment day/time:
Special instructions/
Requests for specific date(s):
Results should be sent to:
Physician's Full Name:
Best time to reach you:
PART D
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PLEASE NOTE: This form only generates a request; someone will contact you to schedule your appointment.