Jump to Content

Available Forms

Medical History/Preventative Update

Please List Approximate Date of Last Proceedure

Females age 40-75 (Every two years or more frequently if recommended by your physician)
Females ages 20-65 (Frequency every 1-5 years depending on physician recommendation)
All individuals over age 50 -75 or other high risk individuals identified by your physician. Frequency is every 1,3 ,5 or 10 years based on the results and your risk factors
All individuals over 65 or older or other individuals identified as high risk by a physician should receive the vaccine
Male 65-75 that has smoked more than 100 cigs in lifetime
Female > 50 or Male or Female identified by your physician at high risk
* Required field