5^th Annual Prostate Cancer and Men's Health Day

September 12^th, 2026 from 8am-12pm

Hampton University Proton Cancer Institute

40 Enterprise Pkwy, Hampton VA

In partnership with Hampton University's Proton Cancer Institute, Sentara Health, and Hampton Roads Prostate Forum.

Please complete this form to register for the event and, if applicable, for cancer screening(s). A team member may contact you if additional information is needed.

Your Information

Note: Asterisk * indicates a required field

Form

First name*

Last name*

Date of birth*

Birth Month

Birth Day

Birth Year

Home address 1*

Home address 2

City*

State*

ZIP code*

Phone number with area code*

Email address*

Race/Ethnicity*

Have you attended the HUPCI Men's Health Fair before?* Yes No

What is the name of your primary care provider? If you don't have a primary care provider, please type "N/A" *

Do you have health insurance?* Yes No

If you have health insurance, please write the insurance carrier name and ID in the text space below. If you do not have health insurance please type "N/A" *

Event and Screening Interest

Choice (multiple answers accepted) - Which screening(s) are you interested in?

Screenings provided by Sentara Health

Breast (Mammogram) Prostate

Screenings provided courtesy of VCU Massey Cancer Center, Hampton University Speech, Language, and Hearing Clinic, and INTEGRITY Skin & DermCare

Colorectal Head & Neck Skin

Other

Event Attendee only Not sure - walk ins welcome!

Sentara Cancer Screening - Eligibility

To be eligible for a breast and/or prostate cancer screening, you must meet the clinical elgibility criteria. Please review the statements below (select only one answer choice)*

I am at least 40 years old
I do not have a new breast mass, lump, bump, discharge, discoloration, or another new change to my breast
I am not experiencing new and worsening urinary symptoms including weak, difficult or interrupted flow, blood in the urine, or sudden frequent urination
I am not actively being treated for cancer
In the last 12 months, I have not had a prostate and/or breast screening

Prostate = PSA, DRE
Breast = Mammogram

I confirm that all the statements listed in the “screening eligibility” are TRUE. If you have these symptoms, we will not be able to perform your screening. I confirm that at least one of the statements above is FALSE, which makes me ineligible for a screening. I would like a head & neck, colorectal, and/or skin cancer screening. These eligibility requirements do not apply to me. I understand eligibility requirements for head & neck, colorectal, and/or skin cancer screenings will be provided to me by the organization that is providing the screening. I am not interested in a screening (for event only attendee)

Acknowledgment

I understand these screenings are not a diagnosis and may require follow-up care. You will be notified of your results within 2-3 weeks.* Yes N/A - no screening requested

Screenings provided by Sentara will be billed to your insurance. At Sentara, we provide quality care to all patients, regardless of their ability to pay. Financial assistance may be available for those who qualify.* Yes, I understand N/A - no screening requested

5th Annual Prostate Cancer and Men's Health Day

Your Information

Event and Screening Interest

Sentara Cancer Screening - Eligibility

Acknowledgment

5^th Annual Prostate Cancer and Men's Health Day