• Mammos & More Registration

  • Date of Birth (Must be 40+)*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Select an Appointment Time*
  • Select a T-Shirt Size*
  • Are you an Ambetter or LA Healthcare Connections member?*
  • How did you hear about the event?*

  • Insurance Information

    Please provide your insurance information below:

  • As an Ambetter or Louisiana Healthcare Connections member, you may qualify to earn rewards through your My Health Pays® rewards program. Also, please note that most insurance plans cover screening mammograms only once every 12 months, so before registering, confirm that you haven't had a mammogram in the past year to avoid unexpected out-of-pocket costs.

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  • Payment Information

    Services performed at the event will not be filed with insurance. Any needed follow-up care will be filed with insurance.

  • *

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      Mammos and More Registration
      $25.00$25.00
        
      Total
      $0.00$0.00
      Credit Card
      Billing Address

    • Please answer the following questions to the best of your ability to complete your registration.

    • Do you feel a lump in either breast? Check all that apply: Yes or No and/or Left Breast or Right Breast.*
    • Do you have pain or soreness in either breast? Check all that apply: Yes or No and/or Left Breast or Right Breast.*
    • Do you have discharge or bleeding from your nipples? Check all that apply: Yes or No and/or Left Breast or Right Breast.*
    • Have you ever had breast surgery? Check all that apply: Yes or No and/or Left Breast or Right Breast.*
    • What was the date of your breast surgery?*
       / /
      2 digit month, 2 digit day, 4 digit year
    • What kind of surgery did you have? Check all that apply:*
    • Have you ever been diagnosed with breast cancer?*
    • Has anyone in your family ever had breast cancer?*
    • Have you ever been diagnosed with ovarian cancer?*
    • Has anyone in your family ever had ovarian cancer?*
    • Have you ever been diagnosed with any other type of cancer?*
    • Is there a possibility you may be pregnant?*
    • Have you gone through menopause?*
    • Have you had a hysterectomy?*
    • What is the approximate date of your last menstrual cycle?*
       / /
      2 digit month, 2 digit day, 4 digit year
    • Do you take birth control pills or hormones?*
    • Was your first child born after you were 30 years old? (If applicable)*
    • Have you had a mammogram before?*
    • Approximate date of your last mammogram?*
       / /
      2 digit month, 2 digit day, 4 digit year
    • Should be Empty: