Breast Cancer Screening Client Intake Form

Breast Cancer Screening Client Intake Form
Name

First NameLast Name
Birth month& Year
ZIP Code
example@example.com
Ethnicity
example@example.com
Preferred Language
example@example.com
Preferred method of contact
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Navigator Name
Are You Interested in Participating Breast Cancer screening Program
Do you have Health Insurance ?
example@example.com
If you are uninsured, would you like a referral to assistance finding low-cost or free screening services?
Are you currently facing any challenges/ barriers and need assistance for Breast cancer screening.
Did anyone help you complete this form. If yes, Answer the following questions.
Please enter the name and signature of the person assisted.
I ( Assisted Person) agree that I have assisted the person in filling the Intake form and also agree to the privacy terms of the organization and maintaining all the information confidential.
We respect your privacy and will keep any personal or health-related information you share confidential. If you provide health information, it will be handled in a manner consistent with HIPAA privacy principles. Your information may be shared with referral organizations only with your consent or when required by law or safety concerns. By submitting this form, you agree to this use of your information
Consent: I agree that all the above information is true and I am interested to participate in WMAAA Breast cancer screening Program.
Date

MonthDayYear
Date
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