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.  Enter quantity for the materials requested.

You may also click on the link to view and/or print the document. It is acceptable to print any of the forms on white paper. 

Sage Enrollment Form (blue)
(View Enrollment Form - English (PDF)) (View Enrollment Form - Spanish (PDF))
Sage Imaging Summary (green) 
Form used for reporting results of screening mammogram 
(View Imaging Summary (PDF))
Sage Pap Smear Summary (pink) 
(View Pap Smear Summary (PDF))
Sage HPV Test Summary (yellow)
Form used for reporting results of HPV Test ONLY if your facility does NOT use a liquid-base Pap test
(View HPV Test Summary (PDF))

Patient Enrollment and Tracking Log (for download only)
Patient Enrollment and Tracking Log (PDF)

Sage Screening Program: What it Covers, What it Does Not Cover
Information provided to patients enrolled in Sage to explain the program
(View What it Covers - English (PDF)) (View What it Covers - Spanish (PDF))

Labels with Sage Logo  (for download only)
30 - 1" x 2-5/8" Sage Logo labels per sheet

Logo Labels Template (DOC)

Do you need Encounter # Labels
Customized "Sticky" labels with Sage encounter numbers e.g., XYZ101

Return Mailing Labels (for download only)
Return Mailing Labels template (DOCX)  

Contact Information
All information below is required.
Comments: