• See, Test & Treat Enrollment Form

    See, Test & Treat Enrollment Form

  • To determine if you are eligible to participate in the 2025 See, Test & Treat event, please complete the following information.

  • Personal Information

  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Are you of Hispanic, Latino, or Spanish origin?*
  • Would you like an interpreter for the event?*
  • Do you need help with transportation to the event?*

  • General Questions

  • If you do currently have health insurance, was there a time in the past 12 months when you needed to see a doctor but could not because you could not afford it?*

  • Pap Testing

  • Have you ever had Cervical Cancer Screening (a Pap Smear or HPV test)?*
  • Have you ever been diagnosed with Cervical Cancer?*

  • Mammogram Screening

  • Have you ever had a Mammogram?*
  • Have you ever received a mastectomy or lumpectomy?*
  • Do you currently have any lumps or dimpling in either of your breasts?*
  • Have you ever had breast cancer?*
  • If you have had breast cancer, was your diagnosis in the last 5 years?
  • Are you able to stand and lean forward for 2 minute intervals while images are obtained?*
  • Are you currently pregnant?*
  • Do you currently have breast implants?*
  • Are you currently breastfeeding?*

  • Please hit the Submit button to officially complete the 2025 See, Test & Treat Eligbility Survey. Someone from the Registration Team will reach out to you to get you officially registered for the event, and answer any questions you may have. 

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