Skip to main content

Request for the Moncrief Mobile Clinic

REQUEST FOR MONCRIEF MOBILE SCREENING CLINIC

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 *
Contact Information
Request for Moncrief Mobile Screening Clinic
Screening type requested (select all that apply):
Are you requesting mammograms to be provided at a corporation or workplace for employees?
Is the mobile being requested in conjunction with other vendors (for example, at a health fair or community 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?
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)
Age Range (select all that apply)
Language
Insurance Status (select all that apply)
Insured Types
CAPTCHA