Mammogram Pre Registration Form For UNINSURED Women

Please complete the following Pre Registration Form if you meet the following guidelines:

A Florida resident
Between 40-64 years of age; OR
Under 40 years of age with a family history of breast cancer or symptomatic women may be eligible if no other resources are available in their area;
Have no health insurance to cover the cost of clinical breast exams, mammograms, or pap smears;
Have a household income less than or equal to 200 percent of the poverty level;
Women of any age who have completed treatment for breast cancer may be eligible.

First Name *

Last Name *

Email *

Phone *

Date of birth *

Age *

Address *

City *

State *

Postal code *

What county do you live in? *

MASS© Event Locations and Pre-Screening Questions

Which event are you preregistering for? *

Tues., Oct. 14, 2025 - (EATONVILLE, FL) at Macedonia Missionary Baptist Church

Fri. Oct. 17, 2025 - (LAKE CITY, FL) at La Quinta Inn & Suites by Wyndham

Sat., Oct. 18, 2025 - (OVIEDO, FL) @ Florida Breast Cancer Foundation Race to Cure at Oviedo Mall

Sat., Oct. 25, 2025 - (FT. MYERS, FL) at St. Johns 1st Missionary Baptist Church

Sat., Oct. 25, 2025 - (DAYTONA, FL) with Alpha Kappa Alpha Sorority, Inc., Gamma Mu Omega Chapter

Sat., Nov. 1, 2025 - (DELTONA, FL) at New Hope Church

Do you have insurance? *

Yes

Have you ever had a mammogram? *

Yes

IF YES, when was your last mammogram?

In the last year (less than 12 months)

In the last 2 years (more than 1 year, but less than 2 years ago)

In the last 5 years (more than 2 years, but less than 5 years)

5 or more years

I'm not sure

Have you ever been diagnosed with breast cancer? *

Yes

If yes, was your breast diagnosis within the last 5 years?

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 hereby consent to The Beautiful Gate Cancer Support and Resource Center sharing my preregistration form with the Florida Department of Health Breast and Cervical Cancer Early Detection Program, as well as other community partners involved in my breast healthcare. Additionally, by providing my phone number and email address, I acknowledge and accept the terms and conditions established by The Beautiful Gate Cancer Support & Resource Center. I also authorize The Beautiful Gate Cancer Support & Resource Center, the Florida Department of Health Breast and Cervical Cancer Early Detection Program, and relevant community partners to contact me via phone calls, text messages, or email regarding matters related to my breast healthcare.

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