download the application yourself. - Pinellas County Health ...

NOTICE REGARDING PRESCRIPTIONS FOR MAMMOGRAMS
IF YOU HAVE A CURRENT PRESCRIPTION FOR A MAMMOGRAM,
YOU MUST SEND IT WITH YOUR APPLICATION. PLEASE ATTACH
THE PRESCRIPTION TO THIS DOCUMENT.
ALSO, PLEASE INDICATE BELOW IF YOU HAD A BREAST EXAM*:
□ Yes, I had a breast exam* when I was given my prescription.
□ No, I did not have a breast exam* when I was given my prescription.
□ I do not have a prescription.
*A breast exam is when the examiner feels your breasts for lumps.
NOTE: If you answered “No”, you can still participate in our program. We will
simply schedule a breast exam for you at one of our locations before we schedule
your mammogram.
Should you have any questions or concerns, please feel free to call on us at the
number indicated below.
We are glad you are taking care of your breast and cervical health.
THANK YOU,
FBCCEDP Staff
Name: ____________________________ Date of Birth: __________________________
Date: _____________________________ Signature: ________________________________
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