Mother's Day Mammogram Event

BarbaraCares: Mother's Day Mammogram Event
BarbaraCares in partnership with THR is offering FREE mammogram screenings onsite at Parkside Missionary Baptist Church. As we celebrate Mother's Day, we encourage residents to take part in personal self-awareness and self-care through proactive health screenings. Appointments slots are limited and must be pre-scheduled.
Call (855)-318-7696 Monday - Friday to schedule.

TO INQUIRE ABOUT AVAILABLE SPOTS PLEASE CALL 855-318-7696

PARA PREGUNTAR SOBRE LOS LUGARES DISPONIBLES, LLAME AL 855-318-7696

* Indicates required field

Name *

First

Last

Email *

Birthdate MM/DD/YYYY *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Race / Ethnicity *

Last Date of Mammogram? *

Do You Currently Have Insurance? *

Total Annual Household Income? *

What is your current employment status? *

Employed Unemployed Self-Employed Student

Is There History of Breast Cancer In Your Family? *

Yes No

Are You Over The Age of 40? *

Yes No

Signature
Please read the following information carefully before signing and submitting: I hereby understand and recognize that the Mother's Day Mammogram Event is part of the BarbaraCares Foundation, a Texas nonprofit corporation which is a recognized tax exempt organization pursuant to Internal Revenue Code Section 501 (c)(3). This program has been solely and exclusively established for the benefit of those persons at-risk of a breast cancer incident, uninsured, or lack the financial means to afford a routine mammography screening here in the state of Texas. Screenings provided are not based on marital status, race, gender, ethnicity, orientation or religion. However, mammograms are granted based on eligibility and age criteria within the designated service area (the state of Texas).

Accordingly, I have read and affirm all the information provided is truthful and accurate. I hereby certify that the financial information disclosed on this application concerning my annual household income, expenses and insurance provider is true and accurate. I understand that if any of the information set forth above is false, the application will be denied and if funding has been released, the foundation will pursue any and all legal means available to retrieve disbursed funds.

By signing the signature/clicking the submit button below, I agree and give permission for the BarbaraCares Foundation to verify the provided information.

Submit

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