2020 Client Screening and Application Form – Gift of Life

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 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-speaking 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

SPONSORSHIP RESPONSE