Urologic Cancer Risk Assessment

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 assessment below to determine if this program is appropriate for you. If you are eligible, a referral specialist will contact you within two business days to gather more detailed information.

Fields marked with an asterisk * are required.

Personal 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?

General Information

Your The Patient's Contact Information

Would you  the patient like to join our mailing list?

Your Patient's Residential Address

Your Patient's Insurance Information Optional

Your The Patient's Physician Information Optional

Risk Assessment

Urinary System Health

Do you have difficulty with urination? *
Have you noticed blood in your urine? *
Do you have a hyperactive bladder? *
Do you have issues with the sudden urgency to urinate? *
Are you suffering from kidney stones? *
Do you have pain in your flank? * Flank pain is pain in one side of the body between the upper belly area (abdomen) and the back.

Reproductive System Health

Do you have difficulties with erections and/or ejaculation? *
Has your primary care physician told you that your PSA is elevated? *
Do you have scrotal swelling and/or pain? *