Buddy Bus Patient Registration Form - Jaguars vs. Giants

YOU MUST HAVE A VALID TICKET TO THE GAME TO REGISTER FOR THE BUDDY BUS.


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 within 2 business days.


EVENT TIME: 10:00am - 2:00pm

EVENT DATE: October 23, 2022

EVENT LOCATION: TIAA Bank Field - Fan Zone



Questions?

Please contact BuddyBus@bmcjax.com



This form will take 5-10 minutes to complete.

Patient Information

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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 any history of breast surgery?*
Do you have breast implants?*
Select your implant type:*
Are you currently using contraceptives?*

If you've never used contraceptives please type N/A.

Please select all that apply.

Do you have any family history of the BRCA gene?*

Provider to send results to:

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