DCH Health System Screening Event

DCH Health System Breast Cancer Screening Event

October 2, 2023
Exclusivo para la comunidad Latina: 16 de octubre, de 5 a 7 p.m. Tendrá que preregistrarse para el 5 de octubre. Haga clic aquí https://hipaa.jotform.com/232265351482151.

Sponsored by the DCH Foundation's Breast Cancer Fund, we invite West Alabama women to the free breast screenings on Monday, October 2nd from 5-7pm.

Criteria for Participation:
- No personal history of breast cancer
- No health insurance
- At least 12 months since last mammogram
- Must live in the DCH service area
- For women 25-39 years old, mammograms will only be ordered if the provider recommends
Name*

First NameLast Name
Email
example@example.com
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Residence
Date of Birth*

MonthDayYear
Please provide your date of birth.
Women ages 25-39 will receive a clinical breast examination and education. Mammograms will only be ordered if the provider recommends.
Last 4 Digits of Your Social Security Number (if applicable)
Please enter the last 4 digits of your Social Security Number (if applicable)
BillboardChurchDCH WebsiteNewspaperPreviously AttendedSocial Media (Facebook)The Links Incorporated
Do not have a healthcare providerGood Samaritan ClinicHealth DepartmentMaude Whatley ClinicUniv Medical Center (UA)Other
YesNo
You will be responsible for any deductibles associated with imaging (mammograms, ultrasounds, etc). Please bring your insurance card.
Insurance Information
Insurance Provider
Please provide the name of your insurer
Policyholder Name
Please provide the name of the policyholder; this may also be called Subscriber
Policyholder Date of Birth

MonthDayYear
Please provide the date of birth of the policyholder
Contract Number
Group Number
YesNo
YesNo
Age*
African American/BlackAmerican Indian or Alaskan NativeAsian AmericanCaucasian/WhiteHispana/LatinaOther
USOutside the US
Where (country) were you born [Other]?
Please provide your country of birth
YesNoUnknown
12 or more
YesNoUnknown
7-1112-1314 or older
No births< 20 years old20-24 years old25-30 years old30 or olderUnknown
NoneOneMore than oneUnknown
Please select an appointment time:*
Please arrive at your selected appointment time to complete the remaining paperwork.

Everyone must check in at main cancer center entrance: bottom/main floor of the Manderson Cancer Center.

You will be scheduled an appointment for a *free mammogram.
Should you need to cancel, please call (205)759-7877.
*If you have insurance, you will be responsible for any deductibles associated with the mammogram. Please bring your insurance card.

Mammograms for women 25-39 will only be scheduled if recommended by the provider.

If you have a physician AND insurance, it would be best to contact your physician for a yearly appointment to ensure continuity of care.
Should be Empty:

DCH Health System Breast Cancer Screening Event

Insurance Information