Free Breast Cancer Screening

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 mammograms 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 mammogram 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 the cost of a mammogram?

Yes No

What is your family's income?

$ per (required)

How many does this support?

How did you hear about United Breast Cancer Foundation's Free Mammogram 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?

Free Breast Cancer Screening

Michelle's Story