BreastScreen WA
Request for a FREE Screening Mammogram 
for women with no breast symptoms only

This screening program targets women aged 50 to 74 years with no breast symptoms, for the purpose of detecting breast cancer at an early stage before it can be felt or noticed. 

PATIENT DETAILS
Name: <<Patient Demographics:Full Name>>
DOB: 	<<Patient Demographics:DOB>>	Medicare number: <<Patient Demographics:Medicare Number>>
Address: <<Patient Demographics:Address>>
Telephone: Work: <<Patient Demographics:Phone (Work)>>  Home: <<Patient Demographics:Phone (Home)>>  Mobile: <<Patient Demographics:Phone (Mobile)>> 

REFERRING DOCTOR
Name: <<Doctor:Full Details>>
Date: <<Miscellaneous:Date>>

When you come for your mammogram please:
•	Bring previous breast X-rays, if possible
•	Wear a two piece outfit
•	Do not wear talcum powder or deodorant
•	Arrive 10 minutes early as there will be forms to complete and if required please bring your reading glasses.

METROPOLITAN CLINICS:
Cannington: Suite 1, Shop 15A, Primewest Cannington, 1490 Albany Highway
Cockburn: Cockburn Integrated Health & Community Facility, Cnr Beeliar Dve & Wentworth Pde, Success
East Perth – Mardalup: Ground Floor, 63 Adelaide Terrace
Mandurah: Level 1, 3/61 Sutton St
Midland: Shop 14/27 Old Great Northern Highway
Mirrabooka: 29 Yirrigan Drive
Padbury: Hepburn Heights Shopping Centre, Unit 8/6 Blackwattle Parade
Perth – David Jones Rose Clinic: Level 3, Perth City store
Rockingham: 2/12 Leghorn St
Wanneroo: ECU Health Centre, Level 2, 30 Dundebar Road

RURAL SERVICE: There is a screening and assessment service in Bunbury (South West Health Campus, corner of Bussell Highway and Robertson Drive) and four mobile BreastScreen WA services which visit country towns every two years. Some towns are visited annually. 

Book online for all screening appointments
www.breastscreen.health.wa.gov.au 
Bookings 13 20 50  	http://relayservice.gov.au/