PBH English Screening Form

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

By filling out this form, you are stating that you are interested in getting information from Panhandle Breast Health about a no-cost mammogram.
Legal Name*

First NameLast Name
Preferred Name (If applicable)
Last 4 digits of your Social Security Number
Date of Birth (MM- DD- YYYY)*

MonthDayYear
Date
Primary Email Address*
example@example.com
Preferred Phone #*
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?*

YesNoI'm not sureMedicare / Medicaid
age 65
Which facility would you prefer to get your screening done? They will contact you to schedule an appointment*

BSA/Harrington Breast Center in AmarilloPampa Regional Medical Center in Pampa
Do you have a primary health care provider?

YesNo
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.

YesNo
Have you had a mammogram before?*

YesNo
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?

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

YesNo
Have you had a pap smear in the past?

YesNoI no longer have/never had a cervix.
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?

FacebookReferred by friends/familyReferred by doctor or health professionalHealth Fair/EventOther
Type a question
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