Healthy Women are Happy Women

Brought to you by CDC, HRSA, DOH-Madison, Madison County Memorial Hospital, and Mobile Wellness Unit. This initiative serves the north Florida area to enable qualifying women to receive free screenings and counseling about their risk for heart disease and stroke. Women are supported by a Resiliency Coach who walks along beside them to encourage them to get screened for risk factors, provides encouragement and support, and coordinates referrals to a variety of resources to help each woman reach their health and fitness goals. A Wellness Ambassador helps identify community wellness resources and works hand-in-hand with you and your coach to provide enhanced services.

Ready to sign up today, scroll to the bottom of the page and fill out the form to get started.

Get Started Today! Click if you prefer to download, save the form and return it via fax, eMail or traditional mail. Call a Wellness Ambassador or Resiliency Coach at 850.253.1907 for assistance or to sign up over the phone.

Wise Woman Client Agreement Form

MCMH has your back! TeleCardiology provides emergency access to Cardiologist in case of an emergency. But don't wait for an emergency, be proactive in maintaining heart health. Fill out the Women's Wellness Client Consent Form below and a coach will contact you shortly.

Breast Cancer screening is the key to survival from this type of cancer. If you have a family history of breast cancer, early detection and self-exams make all of the difference. Click here to schedule a mammogram or Call 850.253.1907 to connect with a coach and receive additional resources to help you with your quest to fight/prevent breast cancer.

Healthy eating doesn't have to be YUCKY! Nor does it have to be a chore. Join Healthy Your for Women and get the support you need to maintain a healthy diet. Participate in chef demonstrations, share and receive recipes and nutrition education. Connect with a coach to have ongoing support in your quest to cook and eat healthy.

Or check out our recipes for ideas and inspiration brought to you from the Diabetic Exchange.

Use our online forms to get started and a Wellness Ambassador or Resiliency Coach will get in touch with you shortly. If you have any questions please call 850.253.1907.

Contact Us

Wise Woman Client Consent Form

This form is required for participation in Wise Woman

Name*
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Cell Phone
Email
Emergency Contact*
Contact Relationship*
Contact Cell or Home Phone*
Consent by entering your initials*

The Florida Department of Health invite you to take part in the WISEWOMAN programs. If you agree, you will receive your breast and cervical cancer examinations, assessments for heart disease and stroke, referral to approved healthy behavior support options and routine follow-up from a WISEWOMAN community health worker.
Client Agreement consent by entering your initials*

-I have not supplied documentation of household income. I declare my household income is within BCCEDP/WISEWOMAN present income guidelines. -A staff person has informed me of which tests the WISEWOMAN programs cover and possible side effects of the tests. -I understand that the WISEWOMAN services will be available to me at no cost. -I understand that my health is my responsibility. I am responsible for keeping my appointments. -I understand that persons associated with WISEWOMAN may contact me in receiving medically recommended services. -I understand that I need to contact this clinic for my test results. -I understand that no test is 100% accurate. -I agree to participate in both the screening tests and the WISEWOMAN lifestyle education sessions. -I understand that I will be contacted to return in one (1) year to see if my health status related to these services has changed. -I have read or had the above read to me. I agree that all the information above is correct.
Consent by clicking the box below*
I consent to the conditions of the Wise Woman program.
With your consent, as a client receiving services funded by WISEWOMAN, your protected health care information will be shared with appropriate staff at the Florida Department of Health and other agencies as required by the federal funding source. I acknowledge that I have been given a copy of the Florida Department of Health Notice of Privacy Policies and have been told where I can obtain any subsequent revisions to this Notice. If this document is signed by the guardian or Durable Power of Attorney for Health Care (DPOA-HC), attach a copy of the Letters Appointing the Guardian or a copy of the Durable Power of Attorney for Health
Participant Signature (Type first and last name to consent)*
First Last
Witness Signature (Type first and last name of person witnessing this form)*
First Last
Today's Date*
MM slash DD slash YYYY

For Wellness Ambassadors and Resiliency Coaches Only:

Wise Woman Screening Form

Wise Woman Referral Form

Wise Woman Coaching Assessment