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
Legal Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Medical Sex*
Gender Identity*
Age*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Best Contact Phone Number:*
E-mail
example@example.com
Preferred contact method*
Which of the following describes your race?*
Are you of Hispanic, Latino, or Spanish origin?*

YesNoDecline to Answer
What is your preferred language?*
Would you like an interpreter for the event?*

YesNo
Do you need help with transportation to the event?*

YesNo
General Questions
What kind of Health Insurance do you currently have?*
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?*

YesNoI do not have insurance
Pap Testing
Have you ever had Cervical Cancer Screening (a Pap Smear or HPV test)?*

YesNoDon't Know/Not Sure
If you have had a Pap Smear, when was your last one? If no pap in the past, enter NONE. *
Have you ever been diagnosed with Cervical Cancer?*

YesNoDont' Know/Unsure
Mammogram Screening
Have you ever had a Mammogram?*

YesNoDon't Know/Not Sure
If you have had a mammogram in the past, how many years has it been? If no mammogram in the past, enter NONE. *
If you have had a mammogram in the past, where did you receive your mammogram? If you do not know, enter unsure.*
Have you ever received a mastectomy or lumpectomy?*

YesNoDon't Know/Unsure
Do you currently have any lumps or dimpling in either of your breasts?*

YesNo
Have you ever had breast cancer?*

YesNo
If you have had breast cancer, was your diagnosis in the last 5 years?

YesNoNot Applicable
Are you able to stand and lean forward for 2 minute intervals while images are obtained?*

YesNo
Are you currently pregnant?*

YesNo
Do you currently have breast implants?*

YesNo
Are you currently breastfeeding?*

YesNo
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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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

General Questions

Pap Testing

Mammogram Screening