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United Breast Cancer Foundation

Free Breast Screening Application

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.

Please help support this wonderful program.

 

Request a Breast Screening Form

Referred By:

Date:

    
First Name:

Last Name:
Birth Date:

    19
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

Have you ever had a Biopsy?
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 Breast Screening? 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 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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