Baylor Health Care SystemAbout B

Breast Imaging

Baylor Regional Medical Center at Grapevine

 
Need something? Call us: 1.800.4BAYLOR(1.800.422.9567)
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Medical History Form 

If you scheduled your screening mammogram or diagnostic mammogram appointment over the phone, please complete the online medical history form below in order to expedite your visit.

  • Once you have completed and submitted the form, you will receive an email confirming receipt. When you arrive for your appointment, you’ll be asked to confirm your information.
  • Please note that diagnostic mammograms are by physician referral only, and you must call 817.329.2501 to schedule. 
  • If you scheduled your screening mammogram appointment using our online tool, you have already completed your medical history and there is no need to complete this form. If you have not scheduled a screening appointment yet, please do so using our online tool or by calling 817.329.2501.
Patient Information

First Name*
Last Name*

Date of birth*

Primary phone number*
Secondary phone number

Email Address*
Confirm Email Address*