One moment please...
Breast Screening Registration
Please select your preferred screening date.
Thursday, April 18th, 9 AM - 3 PM at GRAAHI Office
Saturday, May 4th, 9am-2pm at Messiah Baptist Church
Wednesday, June 12th, 9am-2pm at Pilgrim Rest MB
Saturday, August 17th, 9am - 2pm at Rhythm Health Fair | MLK Park
Name
*
First Name
Last Name
Email
*
Verify Email
*
Zip Code
*
Phone
What is Your Date of Birth?
*
What is your Gender?
Male
Female
Non-binary
Transgender Man
Transgender Woman
I prefer not to disclose
Other:
What is your race? (Please select ALL that apply)
American Indian or Native Alaskan
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Multiracial
Prefer not to say
Ethnicity
Hispanic
Non-Hispanic
Have you had a previous mammogram?
*
Yes
No
If YES, how long ago and where did you have the mammogram?
Do you currently have a primary care medical provider?
Yes
No
I need one.
Do you currently have insurance? (Not required, but bring your card if you have insurance)
*
Yes
No