BECAUSE OF THE DIFFICULTIES ENCOUNTERED WITH E-MAIL HANDLERS ON DIFFERENT HOST COMPUTERS AND THE ABILITY TO EASILY SEND THE E-MAIL, THIS PAGE IS SET-UP TO CUT AND PASTE INTO YOUR E-MAIL PROGRAM.
Please be sure that both your e-mail program and WEB browser are open so that this form can be sent. 

Copy the information below (highlight, ctrl C) to your e-mail program message area (ctrl V) and then complete the information there.

Send to tcpayne@uky.edu

Add or delete responses as appropriate:

New participant?: yes or no
Age: _____
Number of Children:_____
Did your mother, sister, grandmother or aunt ever have ovarian cancer? yes or no
Did your mother, sister, grandmother or aunt ever have breast cancer? yes or no
Have you ever had breast cancer?
Are you or have you taken: tamoxifen (yes or no); Evista (yes or no)
Are you coming to screening as part of a group? (yes or no)
Name of Group Contact :___________________________
Group Contact Phone:__________
Group Contact e-Mail:__________
Group Contact Affiliation: _________
Number in the group being scheduled _____________
Name of Person to be Screened:_______________________
Address:_________________________________________
City: ____________________________________________
State:________
Zip:__________
Work phone #:________________
Home phone #:________________
fax:_________________________
e-Mail:_______________________

PLEASE REMEMBER THAT SCREENING APPOINTMENTS CAN BE FILLED UP 2 MONTHS IN ADVANCE
Indicate the month you would like to schedule for by typing an "X" in the appropriate space:
January ___, February ___, March __, April ___, May ___, June ___, July ___,

August ___, September ___, October ___, November ___, December ___

Indicate the day of the week preference you have and copy the time choice beside it:
 

If there is any special request or information you want to add, please enter it below:

Send to tcpayne@uky.edu