Sage Clinical Forms and Supplies Order Form

Clinics participating in Sage may order the following materials free of charge by completing and submitting this form.

Image  (Click on image to enlarge)

 Title IC# Quantity
Sage enrollment form Enrollment Form (blue)-English (PDF: 25KB/1 page) 140-0031 Quantity-English
Enrollment Form (blue)-Spanish 140-0033 Quantity-Spanish
Sage imaging summary form Imaging Summary (green) (PDF: 239KB/2 pages)
Form used for reporting results of screening mammogram		 140-0024 Quantity
Sage Pap smear summary form Pap Smear Summary (pink) (PDF: 24KB/1 page)
Form used for reporting results of Pap smear		 140-0026 Quantity
Sage HPV Test Summary HPV Test Summary (yellow) (PDF: 52KB/1 page)
Form used for reporting results of HPV Test ONLY if your facility does NOT use a liquid-base Pap test		 140-0627 Quantity
Sage tracking log Tracking Log (PDF: 41KB/3 pages)
A spreadsheet for keeping track of Sage enrollees and the services provided to them		 140-0600 Quantity
Sage Information for Women Enrolled form Sage Screening Program: What it Covers, What it Does Not Cover - English (PDF: 197KB/1 page)
Information provided to patients enrolled in Sage to explain the program 		 141-0358 Quantity-English
Sage Screening Program: What it Covers, What it Does Not Cover - Spanish
Information provided to patients enrolled in Sage to explain the program 		 141-0948 Quantity-Spanish
Labels with Sage logo Labels with Sage Logo
"Sticky" labels of 30, 1"x2-5/8" labels per sheet		   Quantity
XYZ101
*Customized		 Encounter # Labels
"Sticky" labels with Sage encounter numbers		    

*Clinic's 3 letter code

*Last # you have

Quantity

Sage return mailing labels Return Mailing Labels 375-0945 Quantity

 

To order: All information below must be completed before submitting request.

Name
Agency
Address
City 
State 
Zip
Telephone

County
E-mail
Comments:

  

Your order will be sent within 5 business days.

Updated Thursday, 28-Mar-2013 09:17:01 CDT