CRL Imaging Southdale / Women's ImagingFirst Name*Last Name*Date of Birth* Date Format: MM slash DD slash YYYY Primary Care Doctor/Provider*Home Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home Phone*Cell PhoneEmail* Please indicate the service(s) needed below* Mammogram Upright Stereotactic Breast Biopsy Ultrasound-Guided Breast Biopsy Breast Ultrasound Ultrasound-Guided Cyst Aspiration X-Ray Ultrasound Fine Needle Aspiration (FNA) Thyroid DXA Bone Density Which technology do you prefer?* 2D (Digital) Mammography 3D Mammography (Tomosynthesis) Would like to learn more Please note: Some insurance providers do not cover 3D Mammography. Please check with your provider prior to your appointment.What is your age?*Under 3535 or OverHave you had a mammogram in the last 12 months?*NoYesPlease select if you have any of the following:* Implants Any Breast Surgery Any Special Needs (i.e. Hearing/Visually Impaired) Need an Interpreter None of These Please specify your breast surgery(s)Please specify your special needsAre you pregnant or may be pregnant?*NoYesHave you nursed in the past 3 months?*NoYesIf you have nursed in the past 3 months, please schedule your Mammogram 12 weeks after the date you stopped nursing.Is this an annual mammogram or do you have new concerns?*AnnualNew ConcernsBriefly explain your new concerns below:Due to your new concerns, please call us after submitting this form at 952-915-4320 and we will assist you with your specific imaging needs.Would you prefer your appointment be the first available or on a specific date?First AvailableSpecific Date (to be indicated below)Please list in order of priority your top three choices for appointment dates: Hours at this facility are: Monday - Friday: 7:30am - 5:00pm Closed Saturday and Sunday1st Choice Date* Date Format: MM slash DD slash YYYY 2nd Choice Date* Date Format: MM slash DD slash YYYY 3rd Choice Date* Date Format: MM slash DD slash YYYY Please indicate below what time of day works best for you:* Morning (7:00am - 12:00pm) Afternoon (12:00pm - 4:00pm) Evening (4pm - Close) Other (please specify) Specific Time of Day*Please indicate below the best way our representatives can get in touch with you:* Home Phone Cell Phone Email Doesn't Matter Can we leave a detailed voicemail on your home phone?NoYesCan we leave a detailed voicemail on your cell phone?NoYesAre you a current CRL patient or a new patient?* I'm a new patient Current patient How did you hear about us?* Friend Edina Magazine Lake Minnetonka Magazine Facebook Instagram Google Ad Other - Please Specify Heard About Us: OtherTerms & Conditions* By checking this box you agree to have submitted nonfraudulent information. CRL is not responsible for loss of information submitted through this online secure form I'm not a robotCAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
