{"id":276727,"date":"2025-09-28T18:45:23","date_gmt":"2025-09-28T18:45:23","guid":{"rendered":"https:\/\/live-southcoast-health-multi.southcoast-health.org\/?page_id=276727"},"modified":"2025-09-29T16:06:15","modified_gmt":"2025-09-29T16:06:15","slug":"request-to-schedule-a-mammogram","status":"publish","type":"page","link":"https:\/\/www.southcoast.org\/es\/request-to-schedule-a-mammogram\/","title":{"rendered":"Solicitud para programar una mamograf\u00eda"},"content":{"rendered":"\n<div  class=\"blockSettings  paddingTopMD paddingBottomSM gravityFormBlock light\" style=\"\"><div class=\"container\">\n\t\t\t<div class=\"grid\">\n\t\t\t<div class=\"col-sm-12\">\n\t\t\t\t    <div class=\"introWithCta leftAlign\">\n            <div class=\"mainCopyWrap\">\n            <h2>Request to Schedule a Mammogram<\/h2>\n    <div class=\"paragraphWrap\"><p>One in 8 women will develop breast cancer in her lifetime. Mammograms are your best friend in this fight.<\/p>\n<\/div>    <\/div>\n        <\/div>\n    \t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"blockSeparator\"><\/div>\n\t\t<div class=\"grid\">\n\t\t\t<div class=\"col-sm-12\">\n\t\t\t\t<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_9' ><form method='post' enctype='multipart\/form-data'  id='gform_9'  action='\/es\/wp-json\/wp\/v2\/pages\/276727' data-formid='9' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_9_17\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Patient Information<\/h2><\/li><li id=\"field_9_6\" class=\"gfield gfield--type-text label-inside gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_6'><span class='gform-field-label__text'>First Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_9_6' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_9_5\" class=\"gfield gfield--type-text label-inside gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_5'><span class='gform-field-label__text'>Last Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_9_5' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_9_11\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_11'><span class='gform-field-label__text'>Date of Birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_9_11'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_11'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_9_11' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_9_11' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_9_11' aria-label='Date of Birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/li><li id=\"field_9_19\" class=\"gfield gfield--type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Address<\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_9_19' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_9_19_1_container' >\n                                        <input type='text' name='input_19.1' id='input_9_19_1' value=''    aria-required='false'    \/>\n                                        <label for='input_9_19_1' id='input_9_19_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_9_19_3_container' >\n                                    <input type='text' name='input_19.3' id='input_9_19_3' value=''    aria-required='false'    \/>\n                                    <label for='input_9_19_3' id='input_9_19_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_9_19_4_container' >\n                                        <select name='input_19.4' id='input_9_19_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_9_19_4' id='input_9_19_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_9_19_5_container' >\n                                    <input type='text' name='input_19.5' id='input_9_19_5' value=''    aria-required='false'    \/>\n                                    <label for='input_9_19_5' id='input_9_19_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_19.6' id='input_9_19_6' value='US' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_9_20\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Your Contact Information<\/h2><\/li><li id=\"field_9_2\" class=\"gfield gfield--type-email label-inside gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_2'><span class='gform-field-label__text'>Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_2' id='input_9_2' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_9_3\" class=\"gfield gfield--type-phone gfield--phone-format-standard gfield--width-full label-inside gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_3'><span class='gform-field-label__text'>Phone<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_9_3' type='tel' value='' class='large'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/li><li id=\"field_9_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Best time to reach you<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_9_21'>\n\t\t\t<li class='gchoice gchoice_9_21_0'>\n\t\t\t\t<input name='input_21' type='radio' value='Daytime between 9am - 5pm'  id='choice_9_21_0'    \/>\n\t\t\t\t<label for='choice_9_21_0' id='label_9_21_0' class='gform-field-label gform-field-label--type-inline'>Daytime between 9am &#8211; 5pm<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_9_21_1'>\n\t\t\t\t<input name='input_21' type='radio' value='Evening between 5pm - 9pm'  id='choice_9_21_1'    \/>\n\t\t\t\t<label for='choice_9_21_1' id='label_9_21_1' class='gform-field-label gform-field-label--type-inline'>Evening between 5pm &#8211; 9pm<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_9_18\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Appointment Request Information<\/h2><\/li><li id=\"field_9_13\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_13'><span class='gform-field-label__text'>Date of Last Mammogram<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_9_13'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_13'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_9_13' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_9_13' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_9_13' aria-label='Date of Last Mammogram: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/li><li id=\"field_9_14\" class=\"gfield gfield--type-text label-inside field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_14'><span class='gform-field-label__text'>Where Was Your Last Mammogram?<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_9_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_9_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you have breast implants?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_9_23'>\n\t\t\t<li class='gchoice gchoice_9_23_0'>\n\t\t\t\t<input name='input_23' type='radio' value='Yes'  id='choice_9_23_0'    \/>\n\t\t\t\t<label for='choice_9_23_0' id='label_9_23_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_9_23_1'>\n\t\t\t\t<input name='input_23' type='radio' value='No'  id='choice_9_23_1'    \/>\n\t\t\t\t<label for='choice_9_23_1' id='label_9_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_9_24\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you need Wheelchair Accessibility?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_9_24'>\n\t\t\t<li class='gchoice gchoice_9_24_0'>\n\t\t\t\t<input name='input_24' type='radio' value='Yes'  id='choice_9_24_0'    \/>\n\t\t\t\t<label for='choice_9_24_0' id='label_9_24_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_9_24_1'>\n\t\t\t\t<input name='input_24' type='radio' value='No'  id='choice_9_24_1'    \/>\n\t\t\t\t<label for='choice_9_24_1' id='label_9_24_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_9_16\" class=\"gfield gfield--type-text label-inside field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_16'><span class='gform-field-label__text'>Who is your primary care provider?<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_9_16' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_9_22\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Preferred Appointment Time<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_9_22'>\n\t\t\t<li class='gchoice gchoice_9_22_0'>\n\t\t\t\t<input name='input_22' type='radio' value='Anytime'  id='choice_9_22_0'    \/>\n\t\t\t\t<label for='choice_9_22_0' id='label_9_22_0' class='gform-field-label gform-field-label--type-inline'>Anytime<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_9_22_1'>\n\t\t\t\t<input name='input_22' type='radio' value='Morning: 8am - 11am'  id='choice_9_22_1'    \/>\n\t\t\t\t<label for='choice_9_22_1' id='label_9_22_1' class='gform-field-label gform-field-label--type-inline'>Morning: 8am &#8211; 11am<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_9_22_2'>\n\t\t\t\t<input name='input_22' type='radio' value='Afternoon: 11am - 2pm'  id='choice_9_22_2'    \/>\n\t\t\t\t<label for='choice_9_22_2' id='label_9_22_2' class='gform-field-label gform-field-label--type-inline'>Afternoon: 11am &#8211; 2pm<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_9_22_3'>\n\t\t\t\t<input name='input_22' type='radio' value=''  id='choice_9_22_3'    \/>\n\t\t\t\t<label for='choice_9_22_3' id='label_9_22_3' class='gform-field-label gform-field-label--type-inline'>Later Afternoon: 2pm &#8211; 5pm<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_9' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Submit<\/button> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_9' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' 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