Prostate Cancer Screening

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Personal Information

About You

First name *

Last name *

Date of birth * (mm/dd/yyyy)

Contact Methods

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

Your Patient's Email Address *

Best time to call *

May we say we're calling from Roswell Park? *

Due to HIPAA regulations, Roswell Park will not be able to identify itself to someone other than you or in a voice message, unless you indicate otherwise.

Yes No

May we leave a message if you're unable to answer? * Yes No

How did you find out about this event? *

Please Explain

Screening Timeslot

Demographic Information

About You

Your The patient's race *

In which state were you was the patientborn?

Marital Status

Smoking Status *

Are you Is the patient currently a Roswell Park patient? * Yes No

Patient MRN

Are you currently a patient of our Genitourinary (GU) Cancer Center? * Yes No

Do youDoes the patient have a known familial BRCA mutation or other familial syndromes? *

Yes No

About Your Family

Do you have a family history of prostate cancer? *

Yes No

Are youIs of Ashkenazi Jewish ancestry? *

Yes No Unsure

Military Service

Have you Has the patient ever served in the Military? * Yes No

Your Patient's Mailing Address

Prostate Cancer Screening

In Partnership with the Buffalo Bisons and Fans for the Cure

Personal Information

About You

Contact Methods

Screening Timeslot

Demographic Information

About You

About Your Family

Military Service

Physician & Insurance Information

About Your Primary Care Physician Optional

About Your Insurance Optional

Race and Ethnicity Information