Buddy Bus Patient Registration Form -Mother Midway AME Church

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: Saturday, August 19, 2023

EVENT LOCATION: Mother Midway AME Church, 1456 Vanburen St. FL. 32206



Questions?

Please contact BuddyBus@bmcjax.com



This form will take 5 minutes to complete.

Patient Information

Phone
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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?*

Mammography Questionnaire

Is this your first mammogram?*

Phone
Phone

Please include city, state, and zip code.

Are you pregnant?*

According to the American College of Radiology, screening mammography is NOT recommended for pregnant patients who are at an average or intermediate risk for breast cancer. If you feel you should be considered to receive a screening mammogram, please contact us at (904)

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

Provider to send results to:

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