Thank you for your interest in the Moncrief Cancer Institute mobile screening clinic. Our mobile screening clinic is highly requested in the community and we ask that you submit this form 3 months prior to the requested screening date. We will carefully review each request, and a member of our team will respond to your request within 5 business days. Approval of the requested location and date is contingent upon mobile availability and is up to the discretion of the Moncrief team. Please note we do not bring the mobile screening clinic to apartment complexes or shopping/retails centers. Thank you. Today's Date * MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year20212022202320242025 Year Today's Date * Contact Information First Name * Last Name * Title * Organization * Phone Number * Email * Request for Moncrief Mobile Screening Clinic Requested Screening Date * MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year20212022202320242025 Year Screening Location * Screening Address * City * State * Zip * Screening County * Screening type requested (select all that apply): * Mammography Pap Tests Prostate Screenings Are you requesting mammograms to be provided at a corporation or workplace for employees? * Yes No Is the mobile being requested in conjunction with other vendors (for example, at a health fair or community event)? * Yes No Please list the event * Do you have the space for a 72-foot-long, 14-foot-high, 16-foot-wide mobile screening clinic (approximately 12 parking lot spaces) plus a 10-foot security perimeter around the clinic site? * Yes No Please note: area must be clear of low-hanging wires and trees, steep inclines, and fire lanes/zones. Please provide general information about those who will be receiving services. Gender (Select all that apply) * Male Female Age Range (select all that apply) * 18-39 40-54 55-74+ Language * English Spanish Other Other Language * Insurance Status (select all that apply) * Insured Uninsured Insured Types * Medicare Medicaid Private Insurance Please list private insurance types. * Please provide any additional information you would like us to know about your request. Leave this field blank Submit Request for the Moncrief Mobile Clinic
