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 LOCATION, DATE & TIME:


Titanium Yoga - Fruit Cove

2570 Race Track Rd, Fruit Cove, Florida 32259

Thursday, February 15, 2024

10 a.m. - 2 p.m.


Questions?

Please contact BuddyBus@bmcjax.com



This form will take 5 minutes to complete.

Patient Information

Phone
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List of Insurances Accepted/ Not Accepted

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

Insurance Information

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

If not applicable please type N/A

This can be found on the back of your insurance card. If not applicable please type N/A.

Are you the policy holder?*

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Mammography Questionnaire

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Is this your first mammogram?*

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Please include city, state, and zip code.

Are you pregnant?*

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

Are you breastfeeding?*
Do you have breast implants?*

Provider to send results to:

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