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Cancer Center - See Test & Treat Screening Form

See, Test, & Treat Free Cancer Screening

Personal Information

To determine if you are eligible to participate, please complete the following information.
Full Name*
Address*
City/State/Zip*
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Phone*
Email*
Preferred method of contact*
Date of birth*
What is your age?*
What is your gender?*

General Questions
Have you ever had breast cancer?*
Have you received a mastectomy or lumpectomy?
Do you currently have any type of health insurance?
Do you have to meet a deductible with your insurance in order to have screening mammograms and/or pap testing done?
Does your deductible amount make it difficult for you to get needed screenings?
Does your current health insurance pay for screening mammograms and/or pap testing as a wellness benefit?
Please contact your insurance carrier and/or physician to schedule an appointment. This program is intended for women that do not have adequate insurance.

Lung Screening

Sorry, your age range does not meet eligibility requirements for this Lung screening. Please call 601-815-3572 if you need additional information.
Are you a smoker?*
Do you have a history of smoking?   
Sorry, you do not meet eligibility requirements for this screening. Please call 601-815-3572 if you need additional information.

Pap Testing

Sorry, you do not meet eligibility requirements for this screening. Please call 601-815-3572 if you need additional information.
When was your last Pap?*
Have you had a hysterectomy (partial or complete)?*

Sorry, you do not meet eligibility requirements for this screening. Please call 601-815-3572 if you need additional information.

Mammogram Screening

Sorry, you do not meet eligibility requirements for this screening. Please call 601-815-3572 if you need additional information.
If you had a mammogram in the past, how many years has it been?*

Sorry, you do not meet eligibility requirements for this screening. Please call 601-815-3572 if you need additional information.
Do you currently have breast implants?*

Sorry, you do not meet eligibility requirements for this screening. Please call 601-815-3572 if you need additional information.
Are you currently pregnant?*

Sorry, you do not meet eligibility requirements for this screening. Please call 601-815-3572 if you need additional information.
Are you currently breastfeeding?*

Sorry, you do not meet eligibility requirements for this screening. Please call 601-815-3572 if you need additional information.
Do you currently have any lumps or dimpling in either of your breasts?*

Sorry, you do not meet eligibility requirements for this screening. However, please reach out to the Breast and Cancer Program @ 601-576-7466, who may be able to help.