It is a state and federal requirement that all patients seeking breast imaging have a
breast exam performed by a physician.  This form may be printed by the patient or physician.  The confidential information should be faxed or mailed to The Pink Door for processing. Click here to download the form.

Qualification Requirements:
1. Disqualification from state funded programs because of income bracket.
2. Persons under the age of 40 with a breast finding and/or strong family breast cancer history.
3. No or limited insurance coverage which would result in a "self-pay" hardship regardless of age.*

Disclaimer:
Reserved funds are for breast imaging only and excludes any surgical procedures.

We thank you for your interest in The Pink Door vision.

*THE PINK DOOR RESERVES THE RIGHT TO DETERMINE FUNDING BASED ON INDIVIDUAL CIRCUMSTANCES