Get Gbccedpeligandconsentformrev3-11re-screen.doc

Filling out the Gbccedpeligandconsentformrev3-11re-screen.doc online is a straightforward process designed to facilitate your participation in the Guam Breast and Cervical Cancer Early Detection Program. This guide provides step-by-step instructions to help you complete the form accurately and confidently.

Follow the steps to fill out the form online.

1. Press the ‘Get Form’ button to access the Gbccedpeligandconsentformrev3-11re-screen.doc and open it in your online editor.
2. Begin with the eligibility worksheet section. Fill in your primary physician's name, including their last name, first name, and middle initial. Provide your date of birth in the format MM/DD/YYYY, occupation, age, marital status, and social security number.
3. Enter your home telephone number, mailing address, email address, and place of birth. Include any additional telephone numbers if applicable.
4. Complete your home address, citizenship status, and whether you are a documented resident. Indicate your insurance coverage, family size, and gross income either monthly or annually.
5. In the breast history section, provide the date of your last mammogram and the facility where it was performed, followed by the date of your last Pap test and that facility. Indicate if you have any breast or cervical symptoms, and if so, specify them.
6. Detail any family history of breast cancer and note any personal history of hysterectomy or mastectomy, including reasons if applicable.
7. Address the tobacco use history questions and provide truthful responses about your tobacco use, intentions to quit, and family smoking habits.
8. Read the consent for participation section carefully. Make sure you understand the services covered and the confidentiality of your information. After reading, sign and date the form to affirm your consent.
9. Complete the name and signature of the staff section, creating a record of administrative handling. Mark your eligibility status as either eligible or not eligible, providing details if necessary.
10. Once you have finished filling out the form, you can save your changes, download a copy for your records, print it, or share it if needed.

Complete your Gbccedpeligandconsentformrev3-11re-screen.doc online today to ensure your eligibility for the program.