Request for no-cost mobile screening mammogram for an organization
Texas Southern University Center Breast Cancer Screening and Prevention Center (TSU BCSPC) funded by the Cancer Prevention & Research Institute of Texas (CPRIT) provides no-cost breast cancer screening and diagnostic services, patient navigation/barrier reduction services, and evidence-based culturally appropriate breast cancer awareness and education services for African American and other ethnic minority women. Thank you for your interest in partnering with us to address breast cancer health disparity by providing this crucial services in our community.
What is the name of your organization?
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What is the location/address that the service will be provided?
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What date are you looking to schedule the mobile screening mammogram on? Date option 1
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Month
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Day
Year
Date
What date are you looking to schedule the mobile screening mammogram on? Date option 2
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Month
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Day
Year
Date
What date are you looking to schedule the mobile screening mammogram on? Date option 3
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Month
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Day
Year
Date
Will you have 25 to 30 women scheduled for this mobile mammogram screening event?
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Yes
No
What is name of the contact person for your organization?
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What is email address of the contact person for your organization?
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What is phone number of the contact person for your organization?
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Do you want to stay connected with us by joining our mailing list?
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Yes
No
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