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Request an Appointment with The Ross Breast Center

Please complete the form below to request an appointment with The Ross Breast Center. Someone from our office will be contacting you to confirm your appointment time and location. You may also call (903) 531-5300 or (800) 464-8807 to schedule an appointment or for more information about The Ross Breast Center.

* Indicates required information
Patient Legal Name (First and Last Name): * 
Previous Names: 
Date of Birth: * 
Social Security Number: 
Home Phone 
Work Phone 
Cell Phone 
In the event that we need to contact you regarding your appointment, please check which number you would prefer we reach you at * 


Referring Physician: * 
Insurance: 
Appointment Type: * 

RBC Location: * 





Are you experiencing problems with either breast (this includes lumps, bruising, mass, discharge, or pain)? 

Do you have implants? 

Has someone in your family been diagnosed with breast cancer? 

If you answered "Yes" to the previous question, please list their relationship to you. 
Have you ever been diagnosed with breast cancer? 

If you answered "Yes" to the previous question, at what age were you diagnosed? 
Do you still have both breasts? 

Have you had a mammogram previously? 

If you answered "Yes" to the previous question, please list the facility and approximate date of your last mammogram. 
Are you at least 35 years old? (Patients younger than 35 years old must have a doctor's order to schedule a screening mammogram.)