Genetic Testing Referral

This appointment is for a genetic consult only. Most health insurers provide coverage for an initial genetics consultation; you will likely be responsible for a co‐pay. Please check with your health insurer. If they require a pre‐authorization, you need to request it from your referring or primary care physician. If genetic testing is appropriate, the counselor will provide details on which test(s) you need, answer all questions (costs, etc.), and will assist with the insurance authorization process — all before you are tested.

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

Your biologically assigned gender *

Have you ever been seen at Roswell Park?


The patient's biologically assigned gender *

Has this individual ever been seen at Roswell Park?

Would you  the patient like to join our mailing list?
Patient's Contact Information
YourPatient's Background

Are youIs of Ashkenazi Jewish ancestry? *

Have youHas ever been diagnosed with cancer or a related condition? *

Have youHas received treatment? *

What types of treatment have youhas received? *

Is there an urgent or time-sensitive need or concern for genetic testing? *

Have you Has ever been diagnosed with another cancer or a related condition? *

Have youHas received treatment? *

What types of treatment have youhas received?

Is there an urgent or time-sensitive need or concern for genetic testing? *

Do youes have a family history of cancer? *

Please enter your's blood relative family members who currently have or have had cancer in the past.


This relative is: *


Add Another Family Member

Have you or any of yours or any of their relatives had any genetic testing done related to any potential cancer risk? *


Which genetic test did you have done? *

What were the results of your's previous genetic test? *


Which genetic test was done? *

What were the results of their previous genetic test? *