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Event registration
DR. MARTIN LUTHER KING, JR. DAY OF SERVICE
FREE MAMMOGRAM REGISTRATION FORM
PROVIDED BY ALINEA MEDICAL IMAGING
Saturday, January 15, 2022
10:00 a.m. – 2:00 p.m.
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* Indicates required question
Last Name (Apellido)
*
Your answer
First name (Primer Nombre)
Your answer
Middle Initial (Initial del segundo nombre)
Your answer
Email (Correo electrónico)
*
Your answer
Date of Birth (Fecha de Nacimiento)
*
MM
/
DD
/
YYYY
Primary Phone (Numero de telefono)
*
Your answer
Secondary Phone (Numero de telefono)
*
Your answer
Federal guidelines mandate that we collect data on the legal sex of all applicants. Please report the sex currently listed on your birth certificate. (Genero)
*
Male (Hombre)
Female (Mujer)
Decline to answer (Prefiero no decirlo)
Other (Otro)
Federal guidelines mandate that we collect data on the legal ethnicity of all applicants. Please report the ethnicity currently listed on your birth certificate. (Etnia)
White or European American
Black or African American
Asian American
American Indian / Alaska Native
Native Hawaiian / Pacific Islander
Hispanic
Other:
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Date of last mammogram. (Fecha de la Ultima mamografia)
MM
/
DD
/
YYYY
Are you a resident of California? (Eres un resident de California?)
Yes (Si)
No
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Is your household Income under $40,000? (Es el ingreso de su hogar por debajo de $40,000?)
Yes (Si)
No
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Name of Medical Insurance Plan. (IF none, please write NONE) Seguro medico
Your answer
If you have medical insurance, please indicate the copay amount. (Monto del copal del segura medico)
Your answer
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