Mammography Registration Form

2019 Mammography Screening Registration

Screening mammography will only be performed at the event; if you have a history of breast cancer or other breast problems, you will need to schedule an appointment by calling (205) 731-9380 for an appointment during regular clinic hours. Insurance coverage varies by plan and group; insurance typically covers a screening mammogram every 12 months.
- Date: Thursday, October 10th at The Kirklin Clinic of UAB Hospital 3rd Floor Mammography area
- Time: 4pm - 7pm
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
Last 4 SSN*
Insurance Plan Name*
Insurance Policy Number*
Insurance Group Number*
When was your last mammogram?*
Name of physician to receive your mammogram report*
Primary Phone Number*
Secondary Phone Number
Email*
When is the best time to contact you?
- AM
- PM