Please complete the form below by answering the questions to see if you qualify for a FREE mammogram.
HEALTH INSURANCE
Do you have health insurance? -- Make a Selection -- Yes No
Please contact to your primary physician and inquire about scheduling your appointment. Please note if you are insured: According to the Affordable Care Act, most private health insurers must provide coverage of women's preventive health care – such as mammograms, screenings for cervical cancer, prenatal care, and other services – with no cost sharing.
CONTACT INFORMATION
What county do you live in? Alachua Baker Bay Bradford Brevard Broward Calhoun Charlotte Citrus Clay Collier Columbia De Soto Dixie Duval Escambia Flagler Franklin Gadsden Gilchrist Glades Gulf Hamilton Hardee Hendry Hernando Highlands Hillsborough Holmes Indian River Jackson Jefferson Lafayette Lake Lee Leon Levy Liberty Madison Manatee Marion Martin Miami-Dade Monroe Nassau Okaloosa Okeechobee Orange Osceola Palm Beach Pasco Pinellas Polk Putnam Saint Johns Saint Lucie Santa Rosa Sarasota Seminole Sumter Suwannee Taylor Union Volusia Wakulla Walton Washington
FREE MAMMOGRAM SCREENING QUESTIONS
Have you ever had a mammogram? Yes No If yes, when was your last mammogram? Within the past year (anytime less than 12 months) Within the past 2 years (more than 1 year, but less than 2 years ago) Within the past 5 years (more than 2 years, but less than 5 years) 5 or more years I am not sure Have you ever been diagnosed with breast cancer? Yes No If yes, was your breast diagnosis within the last 5 years? Yes No Has an immediate family member (mom, daughter or sister) been diagnosed with breast cancer? Yes No Are you experiencing issues with your breasts? Yes No If yes, are you currently experiencing any of the following symptoms? Select all that apply. Lumps Nipple discharge Pain Swelling None of the above
GENERAL INFORMATION
In order to be screened on the mobile unit you must be able to walk up and down steps with a handrail for assistance.
Are you able to walk up and down five steps? Yes No Are you able to stand unaided for 10 minutes? Yes No Do you have breast implants? Yes No In the last six weeks, have you had a COVID vaccine or do you plan to have one before your appointment? Have you had a COVID vaccine or plan to have one soon? Yes No
PREFERENCE INFORMATION
What is your preferred contact method? Email Phone What is your preferred call time? Morning Afternoon Evening What is your preferred language? English Spanish Other
