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RGH Faculty Breast Practice

1415 Portland Avenue
Medical Office Building (MOB), Suite 245
Rochester, NY 14621
Phone: (585) 922-4715

Non-Urgent Appointment Request

Please complete the form below to request a non-urgent appointment with the RGH Faculty Breast Practice. Our office will contact you within 2 business days with your appointment time. If you do not receive a call from our office, please contact us at (585) 922-4715.

*** IMPORTANT NOTE: Please be sure to bring your breast images (films) with you to your appointment or request that the imaging group who performed your exam send the films directly to us.

Please arrive at least 20 mins in advance to complete the necessary paperwork.

Urgent Appointments

If you have an urgent appointment request (if cancer has been detected), please do NOT use this form. Call our office at (585) 922-4715 to schedule an appointment.

 

Your Information

Name (first name, last name):

Mailing Address:
Home Phone:

Work Phone:

Cell Phone:
Email:
Date of Birth (00-00-0000):
 

Your Insurance Information

Name of Insurance Plan
(i.e., MVP, Blue Cross, etc.)

Subscriber Name:

Subscriber Date of Birth:
(if someone other than you)
Subscriber (or Plan) ID #:
 

Your Physician Information

Primary Care Physician's Name:

Physician's Address:

Physician's Phone Number:
 

Reason for Appointment







** IMPORTANT: If you have Confirmed Breast Cancer, do NOT use this form to request an appointment. Please call our office at (585) 922-4715 to schedule an appointment. We make every effort to see our breast cancer patients within 3 business days.
 

Your Test Information

Please select any tests that you've had before being referred to the RGH Faculty Breast Practice below:

: Date of Test: Imaging Location:

: Date of Test: Imaging Location:

: Date of Test: Imaging Location:

*** IMPORTANT NOTE: Please be sure to bring your breast images (films) with you to your appointment or request that the imaging group who performed your exam send the films directly to us.

 

Our Breast Surgeons

Please select the breast surgeon that you'd like to make an appointment with. Select "first available" if you do not have a preference.





 

Appointment Location

Our breast surgeons see patients at two locations. Please select the location that you would prefer to be seen at.



 

Preferred Appointment Time

Please select the time(s) of day that you would prefer for your appointment. We will do our best to accommodate your request.