MAMMOGRAPHY + COLON CANCER SCREENING

Mammography & Colon Cancer Screening Form

Please fill out the following form.

First name

Last name

Email

Phone

Address

Date of birth

Month

Day

Year

Do you currently live in Virginia?

No

Yes

I am over 40 years of age.

No

Yes

Do you have insurance? (If not, you can still be eligible)

No

Yes

I am over 45 years of age.

No

Yes

What is your ethnicity or Indigenous group?

What is your preferred language?

I am experiencing breast concerns such as:

Lumps

Discharge

Nipple Pain

None of the above

I have NOT been treated for breast cancer in the past 2 years.

I am NOT currently pregnant (no possibility of pregnancy at this time).

I have NOT had a mammogram in the last 365 days.

If you have had a previous mammogram at an Inova facility, please provide the date and facility name.

I am NOT currently lactating or breastfeeding.

I am lactating or breastfeeding and I am 6 months postpartum.

I am lactating or breastfeeding and I have a routine for breastfeeding.

I do NOT have a first-degree relative (parent, sibling, or child) with colon cancer

I have NOT had:

A colonoscopy in the last 7 years
A Cologuard test in the last 3 years
A FIT test in the last 3 months

I am NOT currently experiencing any of the following:

Rectal bleeding
Unexplained changes in bowel habits
Other concerning gastrointestinal (GI) symptoms

If you selected of the answers above, please supply any additional information.

I confirm that the information provided is accurate to the best of my knowledge.

I understand this screening event is for eligibility purposes and does not replace emergency medical care.

I consent to being contacted regarding appointment scheduling and follow-up care.

Initials

I declare that the info I’ve provided is accurate and complete.

How did you hear about this event?

Based on your responses, a member of our care team will review your submission to determine eligibility and be in touch as soon as possible.

I understand

I have a question and will call you at 571-261-2838, or email Cynthia at secretary@vawfsc.org.

MAMMOGRAPHY & COLON CANCER SCREENING EVENT

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