UCHC Mobile Mammogram Screening Registration

Mobile On-Site Mammogram Screening

United Community Health Center
Para ver este formulario en español, haga clic en el menú desplegable en la esquina superior derecha.

If you need assistance registering or filling out this form, please call 520-407-5400 extension 7617.

United Community Health Center is proud to partner with Assure Imaging, the leading provider of mobile digital mammography in the United States. This partnership offers a convenient way for women to receive mammograms with a digital mobile mammography service. Assured Imaging is FDA-approved and ACR certified, utilizing state-of-the-art mammography equipment and certified mammography technologists ensure each patient receives the highest quality of care.

Registration is for registered United Community Health Center (UCHC) patients only. Pre-registration is required. Registration slots are limited.

Mammogram screenings will be aproximately 15 minutes (30 minutes if patient has breast implants), performed by certified mammography technologist from Assured Imaging. Screenings will be held on Monday March 31 at our United Community Health Center - Green Valley clinic located at 1260 S Campbell Avenue Green Valley, AZ 85614. The mobile van will be parked at the front of the parking lot. Registration slots are available from 8am-4pm.
EARLY DETECTION SAVES LIVES!!

All major insurances accepted, no referral needed for annual mammogram screening. All results are sent to patients Primary Care Provider and patient. Please bring picture ID and insurance card to your appointment. A woman is eligible for a digital mammogram screening if she:

• is at least 40 years of age
• has not had a previous mammogram in the past year
• has no current breast problems or complaints
Which provider at UCHC do you normally see?*
You must be a current UCHC patient to register
Patient Name*

First NameMiddle NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number in case we need to contact you.
Email
Enter your email address if you would like an email confirmation of this registration.
Does the patient have breast implants?*

NoYes

Insurance Information
Is the patient the primary Insurance Holder?*

NoYesPatient does not have insurance
Primary Insurance Company Name
Primary Insurance Member ID/Subscriber Number
Primary Insurance Group Number
Please bring a copy of your insurance card(s) and a valid photo ID along to your appointment.

Appointment Selection
This form will register you for a Mammogram screening and will be aproximately 15 minutes (30 minutes if patient has breast implants), performed by certified mammography technologist from Assured Imaging. Screenings will be held on Monday March 31 at United Community Health Center - Green Valley clinic located at 1260 S Campbell Avenue Green Valley, AZ 85614. The mobile van will be parked at the front of the parking lot. Registration slots are available from 8am-4pm.

Choose your timeslot below
Appointment*
I agree that my typed signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing.*

I agree
Electronic Signature*
Please type first and last name
Please type in the word you see below*
Should be Empty:

Mobile On-Site Mammogram Screening

Insurance Information

Appointment Selection