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Secure Appointment Form

Please complete the form below. We will quickly review your information and call you back to discuss your request further. Your personal information is always securely encrypted and protected by the latest in cloud-based firewall technology.

Have you ever been to the Pink Lotus Breast Center?*
Your Name*
First Last
Your DOB*
MM slash DD slash YYYY
Home Address*
Street Address Address Line 2 City State ZIP Code
What best describes your appointment?*
What best describes your new appointment?*
- New diagnosis of breast cancer
- Breast implant removal
- Abnormal Mammogram / Ultrasound / MRI
- Breast Lump
- Breast Pain, Swelling or Bruising
- Nipple Discharge
- Positive Genetic Mutation (BRCA, CHEK2, etc)
- Family History of Breast or Ovarian Cancer
- Second Opinion
- Other
Check all that apply
Please select any additional checkbox(es) above to help us understand what your second opinion is in regards to.
Approximate Date of Diagnosis*
MM slash DD slash YYYY
Approximate Date of Imaging*
MM slash DD slash YYYY
Have you seen a genetic counselor?*
When did you receive your positive test results?*
MM slash DD slash YYYY
Please tell us more about your issue*
In which breast are you experiencing this?*
In which breast do you have nipple discharge?*
Area(s) of Concern in Right Breast*
- Axillary
- Upper Outer Quadrant
- Lower Outer Quadrant
- Upper Inner Quadrant
- Lower Inner Quadrant
- Nipple
Select all that apply
Area(s) of Concern in Left Breast*
- Axillary
- Upper Outer Quadrant
- Lower Outer Quadrant
- Upper Inner Quadrant
- Lower Inner Quadrant
- Nipple
Select all that apply
How long have you been experiencing this issue?*
Want to attach a photo of the concerned area?*
This can provide valuable information for us ahead of scheduling your appointment.
Upload a Photo*
Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 5 MB.
Please keep this file to less than 5MB
We will provide you with cost and timing estimates during our phone call and will answer any specific questions you may have about your planned procedure.
Best Mobile phone number to contact you at?*
Just your number. Do not add a 1 at the beginning.
What is the best time to call?*
Can we contact you via text message about your appointment?*
Email*
So that we can send you necessary paperwork for your appointment
- Get latest updates from Pink Lotus Breast Center

Other Resources

If you don’t know about our partner website Pink Lotus Power Up, make sure to visit it! Power Up is packed with incredible features and has quickly become the most comprehensive breast cancer community and resource site on the Internet.

breast buddies featuring two women dressed in pink image for social media

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The Pink Lotus Breast Center is a comprehensive, integrative and compassionate breast health center exclusively dedicated to the prevention, screening, diagnosis and treatment of breast cancer. Founded in 2007, our center has repeatedly been at the forefront of innovation in the field of comprehensive breast health and cancer care.

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Phone (833) 800-PLBC
Clinical Fax (310) 861-1488

Pink Lotus Breast Center
1260 15th Street
Suite 1109
Santa Monica, CA 90404

Monday – Friday
8:30AM – 5PM
Closed on major holidays

© Copyright 2008-2022 | Pink Lotus Breast Center, LLC | All Rights Reserved

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