$99 Mammogram

Call for an appointment at 866.717.2551 or schedule online at www.SolisMammo.com. Fees will be collected at the time of service (cash, check or credit card) and cannot be filed to an insurance company. A report will be sent to your physician. *This coupon is NOT valid for our centers in Granbury or Weatherford. Please contact these centers to learn more about their cash pay options.

The Solis Value Screening Program is designed to give women who have no insurance, are not eligible for Medicare

or Medicaid, and are facing �nancial hardships an opportunity to get their Annual Screening Mammogram.

Do you have health insurance coverage? Yes NoAre you currently covered by or eligible for Medicare or Medicaid? Yes NoAre you or your spouse employed? Yes NoIf “Yes” does the employer o�er health insurance coverage? Yes NoAre you requesting to participate in the “Solis Value Screening Program” as a result of �nancial hardship? Yes No

This signature certi�es to Solis Mammography that the answers above are true and correct.

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