Buddy Bus Request Form

Buddy Bus Request Form

Thank you for your interest in the Buddy Bus!

Please take a moment to complete the form below. Once received, our team will reach out to you within 3 business days.

The buddy bus travels to locations in Northeast Florida to provide 3D screening mammograms to eligible patients.

We offer full and half day events. For a full day, 8-hour event, we can screen up to 20 patients. For a half day, 4-hour event, we can screen up to 10 patients.

There is no cost to bring the bus to your event. All patients eligible for a screening mammogram will be processed through their insurance.

Patients without insurance may qualify for a no-cost screening mammogram through our partnership with Pink Ribbon Jax.

First Name*

Last Name*

Email Address*

Phone Number*

Phone

Organization*

Provide the name of the organization/company/event requesting the Buddy Bus.

Address *

Provide the address where your event will be held.

Event Date/Time*

Provide the date(s) you'd like to host an event. Please note all events must be scheduled at least 8 weeks in advance.

Intro Meeting Availability*

Provide 3 dates/times over the next 2 weeks you are available for an introductory 30-minute virtual meeting.

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