FREE* Mammogram Request

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

Do you have insurance? *

Yes

Enter Contact Information

First Name *

Last Name *

Email *

Phone *

Date of birth *

Age *

What is your ethnicity? *

American Indian or Alaska Native

Asian / Pacific Islander

Black or African American

Hispanic

White / Caucasian

Two or more ethnicities

Other

Address

City *

State *

Postal code *

What County Do You Live In? *

Free Mammogram Screening Questions

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

If yes, are you currently experiencing any of the following symptoms? Select all that apply.

Lumps

Nipple discharge

Pain

Swelling

Other

None of the above

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 calls, texts and email messages from The Beautiful Gate Cancer Support & Resource Center.

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