Early Screening Access Application

1

Applicant Information

First Name*

Last Name*

Date of Birth*

Sex*

FemaleMale

Phone Number*

Email Address*

Street Address*

Address Line 2

Optional.

City*

State*

ZIP Code*

2

Breast Cancer Risk Assessment

Please select all risk factors that apply to you. This question requires an answer so it is mandatory*

Select all that apply.

Share anything that would help the healthcare provider understand your risk.*

3

Symptoms

Are you experiencing any new breast symptoms or changes, such as a lump, nipple discharge, skin changes, or persistent breast pain?*

YesNo

Important: The Early Screening Access Program supports consultations for screening mammograms only. Individuals with new breast symptoms or changes may require a diagnostic evaluation, which is outside the scope of this program.

4

Healthcare Provider

Do you have a primary care provider or healthcare provider who will manage your follow-up care, if needed?*

YesNo

If yes, please provide your primary health provider's name. If you don't have a primary care provider, enter N/A*

5

Barrier to Care

What barriers have prevented you from obtaining a healthcare consultation?*

Select all that apply.

6

Previous Screening

Have you ever had a mammogram?*

YesNo

7

Medications and Allergies

Please list all prescription medications, and over-the-counter medications you currently take. If none, write None.*

Medication Allergies*

Please list any medication allergies. If none, write None.

Do you have any of the following allergies?*

Select all that apply.

ContrastDyeRadiationNone

Which of the following apply to you?*

Select all that apply.

Do you have any implanted medical devices?*

Select all that apply.

Additional Comments for the Healthcare Provider

Optional. Anything else you'd like the healthcare provider to know.

Privacy Notice

The information you provide in this application will be used solely to determine your eligibility for the Early Screening Access Program and, if approved, to facilitate your virtual consultation with a licensed healthcare provider. ASL Pink Foundation will take reasonable measures to protect your information and will only share it as necessary to administer this program.

8

Program Acknowledgements

Please read and acknowledge the following statements.

I certify that the information provided in this application is true and complete to the best of my knowledge.*

I understand that submitting an application does not guarantee acceptance into the Early Screening Access Program and that, if I am selected, the program covers the cost of the virtual consultation only and does not guarantee that a mammogram order will be issued.*

I understand that this is not a live phone or video consultation and that the decision to issue a mammogram order is made solely by the licensed healthcare provider based on the information I provide in this application. If the healthcare provider needs additional information to complete my evaluation, they may contact me directly.*

I understand that the information provided in this application will be shared with the licensed healthcare provider through RadiologyAssist to conduct my virtual consultation. Once ASL Pink Foundation submits my consultation request on my behalf, I will receive communications directly from RadiologyAssist regarding my consultation.*

I consent to receive program-related communications from ASL Pink Foundation, including updates about my application and a follow-up email or survey.*

Authorization

By submitting this application, I certify that the information provided is accurate and complete to the best of my knowledge. I authorize ASL Pink Foundation to use the information provided in this application solely for administering the Early Screening Access Program and coordinating my funded virtual consultation.

Early Screening Access ProgramApplication

Privacy Notice

Authorization

Early Screening Access Program
Application