Mammogram Pre Registration Form For Uninsured Women

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

A Florida resident
Between 50-64 years of age; OR
Between 40-49 years of age with a family history of breast cancer (i.e. a first-degree relative such as a parent, sister, brother, or child); OR
Symptomatic women who are underage 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? *

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.