Buddy Bus Patient Registration - Winston YMCA

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, June 26, 2025
Thursday, July 17, 2025
Thursday, August 14, 2025
Thursday, September 11, 2025
Thursday, November 20, 2025
Thursday, December 18, 2025

EVENT LOCATION: 221 Riverside Ave, Jacksonville, FL 32202

Questions?

Please contact BuddyBus@bmcjax.com

This form will take 5 minutes to complete.

Patient Information

First name:

Last name:

Date of birth:

mm/dd/yyyy

Phone number:

Phone

Best time to call to schedule an appointment?

On which date would you like to be screened?

Email address:

Mailing address:

(Street, City, State, and Zip code)

Sex:

Race:

List of Insurances Accepted/ Not Accepted

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

Insurance Information

Insurance carrier:

Mammography Questionnaire

Is this your first mammogram?

Yes

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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