Forms for new and current clients

How to become a client 

Follow these steps to become a client:

  • Download each document below
  • Complete your registration form 
  • Have your physician’s office fax or email the completed diagnosis form

Drop forms off at our office or in our dropbox.

How to receive mammogram Services

How to qualify: 

  • Live in Ashland County
  • Uninsured or Low income
  • Denial from UHSMC Financial Assistance Program 
  • Denial from Breast Cancer and Cervical Program

Contact us with any questions you may have

 

Forms to become a Client

Welcome Letter

Download

       registration form

Download

Diagnosis form

Download

Travel Log

Download

Current Brochure

Download

 

“I deeply appreciate all you do for me and other cancer patients as we fight this disease. I thank God for you.” ACCA Cancer Patient

Mammogram Program Forms

Mammogram Brochure


Download

Registration Form 


Download

As you start to address the emotional aspect of your disease you quickly realize the logistic and financial obstacles that are present on your road to recovery. It is truly a blessing to know we have a local agency to not only provide for your spirit but also face and overcome the obstacles along the way. 

Peggy Kohler, Survivor