Buddy Bus Patient Registration - RITA CASH 5k

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: 7:30 a.m. - 10:00 a.m.

EVENT DATE: Saturday, January 13, 2023

EVENT LOCATION: 400 Nocatee Centre Way, Nocatee, FL. 32081



Questions?

Please contact BuddyBus@bmcjax.com



This form will take 5 minutes to complete.

 

Patient Information

 
 
 
 
Phone
 
 
 
 
 
 

List of Insurances Accepted/ Not Accepted

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

 

Insurance Information

 
 

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.

 
 
Drop your files here
 

Mammography Questionnaire

 
 
 
 
 

Provider to send results to:

 
 
 
Phone