Facebook
Twitter
Instagram
CLIENT SCREENING AND APPLICATION FORM
2020 Men's Health and Prostate Cancer Screening Application
Step 1 of 4
25%
Name
*
First
Middle
Last
Date of Birth
*
Date Format: MM slash DD slash YYYY
Age
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
In light of logistical challenges associated with the coronavirus (COVID-19), it is important that we have a phone number an email address on file with your application to facilitate paperless communication. Please provide us with at least a primary phone number, along with a secondary contact phone number if possible.
Primary Phone Number
*
Primary Phone Number Type
*
Home
Mobile
Other
Secondary Phone Number
Secondary Phone Number Type
Home
Mobile
Other
Email
*
Race
*
Asian
Black
White
Other
Ethnicity
*
Hispanic
Non-Hispanic
Your preference for written material:
*
English
Spanish
Vietnamese
Can you speak English?
*
Yes
No
If we cannot reach you, please provide the name and phone number of an English-Âspeaking person we can contact who is authorized to communicate and assist us with your care.
Name
First
Last
Relationship
Phone
Medical
When was your last prostate screening? (mm/yyyy)
Was it provided by Gift of Life?
Yes
No
Has your father, brother or son been diagnosed with prostate cancer?
*
Yes
No
Approximate age
Do you have a physician?
*
Yes
No
Physician’s name/phone:
Financial
How many people are there in your household? (Number including you, your spouse, and any people claimed as dependents on your tax return.)
What is total household gross income (before deductions)?
*
Medicare/Medicaid/Other Insurance
Are you covered by Medicaid?
*
Yes
No
By Medicare Part B?
*
Yes
No
Do you have private insurance coverage?
*
Yes
No
Copay is: ($)
Deductible is ($)
Are you a veteran?
*
Yes
No
How did you learn about this screening? Please mark all that apply. (Your answers will help us reach more men.)
Repeat Gift of Life client
Physician or clinic
Church
TV
Newspaper
Social Media
Library or other public building
Other
Gift of Life Reminder
Friend/Family
Job
Billboard
Sign
Flyer
409.833.3663 | info@giftoflifebmt.org
2390 Dowlen Road Beaumont TX 77706
Facebook
Twitter
Instagram
SPONSORSHIP RESPONSE