UHS Walk-In Mammography Event Registration

Tuesday, Nov. 14

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* 1. First Name

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* 2. Last Name

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* 3. Date of Birth

Please select your date of birth.

Date

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* 4. Date of last mammogram (must be prior to November 14, 2022)

Skip this question if no prior mammogram.

Date / Time

Date

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* 5. Phone Number

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* 6. Email Address