Dignity Health - Free Mammogram Interest Form
In celebration of Breast Cancer Awareness Month, we have partnered with Dignity Health to provide 15 Hmong women to get mammograms at our Women's Health Center in Roseville in November at no cost to them.
Patients would need to be:

-Must be Hmong
-Over 40 years of age
-Asymptomatic - showing no signs of breast issues
-Last mammogram over one year ago
-Patients with insurance are fine but preferably those without insurance or who have high deductibles; this will truly lend the help needed to those who have high out of pocket costs or who just do not have the insurance to cover.

If you or someone you know is interested in this opportunity, please put your registration and contact information below and someone from our team will contact them further for more information.  
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Email *
Are you registering for yourself or someone you know? *
If this registration for someone else, please state who it's for?
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Patient First Name *
Patient Last Name *
Patient Birthday *
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DD
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When was the last time they've had a mammogram? *
Is the client located in Sacramento County? *
Please indicate the client's ethnicity *
Contact Phone Number *
Contact Email Address *
By submitting your information for the Dignity Health - Free Mammogram Interest Form, you are showing intersest in registering for this event.  This interest form does not guarantee your spot as our team will conduct follow up screenings prior to registering for the event.  If you are clear about this statement, please select "I Understand" below to submit your interest form. *
A copy of your responses will be emailed to the address you provided.
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