Become A Patient

Please complete the form below to request a consultation. Once we receive your request, a referral specialist will contact you within one business day to gather more detailed information.

If you're looking to schedule your mammogram, please complete the mammography appointment form.

You may also call 1-800-ROSWELL (1-800-767-9355) to schedule an appointment.

Fields marked with an asterisk * are required.

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About You

First name *

Last name *

Are you calling for yourself, or on behalf of someone else? * For myself For someone else

Date of birth * (mm/dd/yyyy)

About The Patient

Patient's first name *

Patient's last name *

Patient's date of birth *

Your relationship to the patient *

Your Phone Number * (###-###-####)

Contact Methods

Your Patient's Phone number * (###-###-####)

Your Patient's Email Address *

What is the best method to contact you the patient? * Phone call Email

Best time to call you the patient

Select all that apply.

8am - 11am 11am - 1pm 1pm - 3pm 3pm - 5pm

Your Patient's Insurance Information Optional

Primary Insurance Carrier

Group Number

Policy Number

Policyholder

Care Questions

Were you Was the patient advised by your their physician to seek care at Roswell Park? Yes No

Where is the site of concern? *

Do you have Diffuse Large B-Cell Lymphoma? *

What type of Leukemia does the patient have? *

Were you inquiring about Car T Cell Therapy? *

How can we help you?

Your Patient's Residential Address