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.

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:

Police

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?

EMT

9/11

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?

Smoking

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