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Request A Mammogram
Home
Introduction
Appointments for mammograms are scheduled Monday through Friday from 7:15 am (first appointment) until 4:15 pm (last appointment). In order for us to provide you with the best customer service, please provide the following information so we can call you to schedule your mammogram.
Three attempts will be made to contact you, after that we ask you to resubmit this form or call us at 217-223-8400, ext. 4300. Thank you for choosing Blessing Hospital.
Name
First
Last
Address
Address
City/Town
State/Province
- None -
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces (Canada, Europe, Africa, or Middle East
Armed Forces Americas
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federate States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP/Postal Code
Phone Number
Phone
What Is Your Birth Month?
What Is The Best Time To Contact You?
7:15-8:30 AM
8:30-9:45 AM
9:45-10:30 AM
10:30-11:45 AM
11:45 AM-1 PM
1-2:15 PM
2:15-3:30 PM
3:30-4:45 PM
4:45-5:45 PM
Preferred Day For Mammogram
Monday
Tuesday
Wednesday
Thursday
Friday
Preferred Time For A Mammogram
First Appt. (7:15 am)
Morning
Midday
Afternoon
Last Appt. (4:15 pm)
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