Free Breast Cancer Screening

Many women at risk for breast cancer in this country are under insured or do not have any health insurance at all. United Breast Cancer Foundation is proud to be able to offer many women free or low cost breast screenings and follow-up care at their local hospitals and health centers. We are presently expanding this program to service an area near you. UBCF creates partnerships with hospitals covering the costs of a breast screening and any necessary follow-up work for women who otherwise would not be screened.

Referred By:
Name:
Your Birth Date:
Daytime Phone:	( )
Email:
Address:
City:
State:
County:
ZIP:
Sex:	Female Male
Your Doctor's Name:
Your Doctor's Address
Your Doctor's Phone:	( )
Have you noticed any new changes in your breast recently which are not related to monthly discomfort?	Yes No
In which breast?	Left Right Both
Which of the following apply?	Lump Dimpling Redness Change in Shape Rash Bulging Unusual Pain Inverted Nipples Persistent Nipple Discharge
How long ago was your last breast screening?	(years) What type of screening?
Do you have fibrocystle changes in your breast (any new lumps or changes in the way your breasts feel)?	Yes No Don't Know
Have you ever had breast cancer? If so, at what age?	Yes No Age
Is there a history of breast cancer in your family? If so, what is the relation?	Yes No Don't Know Relation
Who's side of the family had this history of breast cancer? At what age?	Mother's Father's Age (if known)
Do you have health insurance, MEDICAID or Medicare that will cover some or all of the cost of a breast screening?	Yes No
What is your family's income?	$ per Year Month Week
How many does this support?
How did you hear about United Breast Cancer Foundation's Free Breast Screening Program?
Would you agree to share your experience with UBCF?
Please include any additional comments, questions or needs you may have.
How did you hear about us?
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