Friends in Pink Free Mammogram Application

  • Friends In Pink Questionnaire

  • DOB*
     - -
  • Today's Date*
     / /
  • Format: (000) 000-0000.
  • Have you received a vaccine in the last 7 days?*
  • Which arm?*
  • Is this a routine mammogram (no symptoms)?*
  • Do you have a lump?*
  • Which side?
  • Have you had a previous mammogram?*
  • Do you have breast implants?*
  • Which side?
  • Any previous breast surgery?*
  • Which Breast?
  • Have you gone through menopause?
  • Any chance you could be pregnant at the time of your mammogram?*
  • Have you given birth to one or more children?*
  • Do you have a personal history of Breast Cancer?*
  • Which Breast?
  • Date Diagnosed
     / /

  • Mammography Financial Assistance Application

  • Date of Birth*
     / /
  • Marital Status
  • Format: (000) 000-0000.

  • Please provide the following information completely and accurately. Information is subject to verification.

  • Are you employed?*
  • Are you insured?*

  • Monthly Income

  • Assets

  • Monthly Expenses

  • Liabilities

  • I hereby apply for financial assistance from Friends In Pink, Inc. I certify the information provided above is an accurate and a true representation of my financial information. I also certify that I have no additional insurance coverage other than stated above. I understand that providing false information will result in denial of assistance from Friends In Pink, Inc. I understand that my credit report will be used to verify this information. My failure to follow through with the application process or take actions to reasonably complete "Patient Eligibility Requirements" may result in denial of this application.

  • Date*
     / /
  •  
  • Should be Empty: