Apply for a Free Mammogram**

This program is designed to help low-income, uninsured women permanent residents of the State of FL receive a one-time free mammogram.

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Name *

First

Last

Address *

City *

ZIP Code *

Contact Phone *

Email (Optional)

Current Age *

Are you currently employed?

• Yes
• No

Do you have health insurance?

• Yes
• No

Are you a permanent resident of the State of FL?

• Yes
• No

You may be asked to provide a copy of a picture ID and/or a copy of a utility bill such as electric, water, cable, or other verifying your name and permanent address.

Have you ever had a mammogram?

• Yes
• No

If YES, which year? *

Where did you take the test?

Results

How did you hear about Yes! to Mammograms?

Any further comments?

Submit

**NOTE: This application is for consideration for a free mammogram while the funds are available.  Please note that you will need an order from a doctor to receive a mammogram.