PBH English Screening Form

Access to Breast and Cervical Cancer Screening by Panhandle Breast Health in collaboration with Haven Health Clinics.

Completing this form indicates your interest in receiving information about free mammograms and low-cost Pap tests.

Legal Name

First NameLast Name

Preferred Name (If applicable)

Last 4 digits of your Social Security Number

Date of Birth (MM- DD- YYYY)

Date

Primary Email Address

example@example.com

Preferred Phone #

Format: (000) 000-0000.

Home Address (Include apt/unit #)

City, State

Zip code

Monthly income before taxes (gross)

How many people, including you, live off the above mentioned monthly income?

Do you have insurance?

Medicare (Part B) and Medicaid cover annual screening mammograms, so you are not eligible for our program. However, PBH will forward your application to the selected facility and they will contact you to schedule an appointment.

Which facility would you prefer to get your screening done? They will contact you to schedule an appointment

Do you have a primary health care provider?

Who is your primary health care provider? (Name of doctor).

Where does this primary health care provider practice? Please provide the name of the hospital or office. Screening results will be sent here.

Are you experiencing any symptoms or breast issues at this time? If yes, you will need a physician's referral to schedule a diagnostic mammogram.

Have you had a mammogram before?

How long ago was your last mammogram? An estimate is fine.

Where did you go to get your mammogram done?

Were the results normal or abnormal?

Other

Would you like for us to send your information to our partner, Haven Health Clinic in Amarillo, to get a free or low-cost pap smear?

Have you had a pap smear in the past?

How long ago was your last pap smear? An estimate is fine.

Where did you go to get the procedure done?

How did you hear about us?

Type a question