Breast Screening Information

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* 1. What is your first name?

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* 2. What is your last name?

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* 3. What is your age?

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* 4. What is your gender?

Female

Male

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* 5. What is your phone number?

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* 6. What is your email address?

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* 7. Do you have health insurance?

Yes

No

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* 8. When was your last clinical breast exam at a doctor's office?

Within the last year

More than a year ago

Unknown

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* 9. When was your last mammogram?

Within the last two years

More than two years ago

Unknown

A West Central District Health Department employee will be contacting you in 2-3 working business days. Please select 'Done' below.