Become A Patient

Please do not utilize this form to request an appointment for COVID-19 vaccination. Requests for vaccination through this form will not receive a response. If you are a Roswell Park patient, you will be notified directly when you become eligible for a COVID-19 vaccine at Roswell Park based on available supply, state eligibility guidelines and other considerations. Please stay tuned to your patient portal and find more information on our vaccine page.

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.

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

Your Information

Are you the patient? *

Contact Information

Best method to contact?

Best time to call Select all that apply.