First Responders Screening Program

Please be aware this program is usually covered by insurance, however, you may be responsible for a copay. If your insurance requires a referral, you will need to obtain one from your doctor.

To determine if this program is appropriate for you please answer a few brief questions.

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.

Fields marked with an asterisk * are required.

Your Information

About You

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

About The Patient

Have you Has the patient ever been seen at Roswell Park? *

Your Patient's Contact information

Contact Methods

What is the best method to contact you the patient? *
Would you  the patient like to join our mailing list?
In the event of cancellation, are youis the patient interested in same or next day appointments? *

Your Patient's Residential Address

Program Questions

First Responder Status

Have you ever been a first responder? *
Please select which type(s) of first responder you have been: *


Firefighter-specific Questions

Which of the following roles do you typically perform on the scene of a structure fire?

Please check all that apply, current or past.

Have you responded to any commercial fires?



Did you respond to 9/11?
Are you enrolled in the WTCHP?

Please take a moment and check your eligibility for the WTCHP.

Second Job

Do you have a second job in addition to being a first responder? *
Does your second job involve manufacturing or fabricating any of the following?
During your second job are you exposed to any of the following?


Are you exposed to second-hand smoke while at work? *

Medical Screening

In the last year have you had any of the following tests:
In the last five years have you had a chest x-ray?

Insurance & Physician Information

Your Patient's Insurance Information

Are you covered by any kind of health insurance or some other kind of health plan?
Please choose a preferred location for the appointment *

Your Patient's Physician Information Optional