Team Maureen

Your Name*

Your date of birth*

YEAR: MONTH: DAY:

You have entered a birthday that makes you under age 13. If you are under age 13, you may not continue and must ask your parent or guardian to complete this reminder request. Additionally, the reminder request cannot be emailed or texted to a person under age 13. The request MUST go to the parent or guardian of the minor child.

By checking this box, you certify that you are the parent or guardian of the person who is underage.

We will not use the email or text contact number in any way, within Team Maureen or outside of our organization, for marketing, sales, distribution or anything else. The information provided is ONLY used for the reminder services offered.

*

YEAR: MONTH: DAY:

Your mobile phone number

Your mobile phone provider

Your email address

I accept full responsibility for all scheduled screenings and vaccine appointments. I understand that electronic reminders are not foolproof, and I have read the terms of use.

Team Maureen

LET US HELP YOU REMEMBER

HPV/CERVICAL CANCER SCREENINGS

SEND ME A REMINDER!