Buddy Bus Patient Registration

Buddy Bus Patient Registration - Titanium Yoga

Thank you for choosing the Baptist MD Anderson Cancer Center's Buddy Bus for your annual mammogram. Once this form has been submitted, you can expect a phone call from our scheduling team one week before the scheduled event.

EVENT TIME: 10:00 a.m. - 2:00 p.m.

EVENT DATE: Thursday, February 20, 2025

EVENT LOCATION: Titanium Yoga - Fruit Cove: 2570 Race Track Rd, Fruit Cove, Florida 32259

Questions?

Please contact BuddyBus@bmcjax.com

This form will take 5 minutes to complete.

Patient Information

First name:*

Last name:*

Date of birth:*

NOTE

If you are under the age of 40, we recommend you call your insurance company to see if a screening mammogram is covered.

Phone number:*

Phone

Best time to call to schedule an appointment?

Select or enter value

Email address:*

Street address:*

Sex:*

Select

Race:

Select

List of Insurances Accepted/ Not Accepted

https://www.baptistjax.com/locations/baptist-medical-center-jacksonville/insurance-information

Insurance Information

Insurance carrier:*

Select

Insurance ID or member number:*

If you do not have insurance or your carrier is not listed please type N/A.

Are you the policy holder?*

Yes

Policy holder first and last name:*

Policy holder date of birth:*

Policy holder employer:*

Picture of Insurance Card - Upload the FRONT of the card*

Drag and drop files here or

Mammography Questionnaire

Is this your first mammogram?*

Yes

Date of last mammogram*

Name of the facility where you received your last mammogram:*

Facility phone number:

Phone

Facility fax number:

Phone

Facility address:

Please include city, state, and zip code.

According to the American College of Radiology, pregnant patients can receive screening mammograms.

Pregnant women under the age of 30 at high risk for breast cancer, pregnant women age 30 to 39 at medium or high risk for breast cancer, and pregnant women 40 and older should receive screening mammography with lead shielding to minimize radiation exposure to the fetus.

Feb 27, 2019

Do you have breast implants?*

Yes

Provider to send results to:

First and last name of primary care provider*

City and State

Send me a copy of my responses

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