Tarjeta de compromiso para la detección del cáncer de colon

Toda la información de evaluación se mantendrá confidencial y se almacenará de forma segura de acuerdo con las leyes aplicables y nuestra política de protección de datos.

Screening Pledge Card

First name

Last name

Address

Phone

Birthday

Día

Mes

Año

Insurance Company

I would like information about planned giving opportunities

Willing to Volunteer?

Ever Had a Colonscopy/Screening?

Personal/Family History of Polyps/Colon Cancer?

Is Transportation preventing you from attending an appointment/procedure?

Comments or special instructions

Transportation Waiver: By participating in this program, I acknowledge that transportation to and from medical appointments may be provided via Uber Health. I release and hold harmless my “Good Shepherd” volunteer, the Greater Chattanooga Colon Cancer Foundation (GCCCF), Volunteers in Medicine (VIM), and Project Access (PA) from any liability arising from transportation services, including but not limited to accidents, delays, or driver conduct.