FREE* Mammogram Request

To sign up for a mammogram in your area, please complete the following Preregistration Form.

If you are not ready to sign-up, please CLICK HERE to return to our website.

Enter Contact Information

Do you have insurance? *

Yes

First Name *

Last Name *

Email *

Phone *

Date of birth *

Age *

Address *

City *

State *

Postal code *

What county do you live in? *

FREE Mammogram Screening Questions

Have you ever had a mammogram? *

Yes

Have you ever been diagnosed with breast cancer? *

Yes

Has an immediate family member (mom, daughter or sister) been diagnosed with breast cancer? *

Yes

Are you experiencing issues with your breasts? *

Yes

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

Are you able to stand unaided for 10 minutes? *

Yes

Do you have breast implants? *

Yes

In the last 6 weeks, have you had a COVID vaccine or do you plan to have one before your appointment? *

Yes

Preference Information

What is your preferred contact method? *

Phone

What is your preferred call time? *

Morning

Afternoon

Evening

What is your preferred language? *

English

Spanish

Other

I agree to terms & conditions provided by The Beautiful Gate Cancer Support & Resource Center. By providing my phone number and email, I agree to receive text and email messages from The Beautiful Gate Cancer Support & Resource Center.