REGISTRATION FORM - Cone Health Mobile Mammogram  Services

Join The Greensboro Chapter of the Links, Incorporated and Mt. Zion Baptist Church for a free Health Fair. Free Mammograms will be provided for women ages 40 and older on Saturday, November 5th at Mt. Zion Baptist Church. 

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* 1. To register for your FREE mammogram, please provide your FIRST and LAST Name in the field below.

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* 2. (Area Code) Phone Number

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* 3. Email Address

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* 4. Are you a woman age 40 or older?

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* 5. For women (age 40+), please provide the approximate date (or year) of your last mammogram.

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* 6. Have you seen a physician or attended a clinic in the last 12 months?

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* 7. Do you have insurance coverage?

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* 8. I have Medicaid or Medicare.

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* 9. What is your preferred appointment availability on Saturday, Nov 5th between the hours of 10 AM - 4 PM (Location: Mt. Zion Baptist Church)?

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