Urologic Cancer Risk Assessment

Personal Information

About You

First name *

Last name *

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

Date of birth * (mm/dd/yyyy)

About The Patient

Patient's first name *

Patient's last name *

Patient's date of birth *

Your relationship to the patient *

Your Phone Number * (###-###-####)

Have you Has the patient ever been seen at Roswell Park? Yes No

Patient MRN

How did you hear about Roswell Park?

Please explain *

General Information

Your The Patient's Contact Information

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

Alternate phone (###-###-####)

Your Patient's Email Address *

Best time to call

Would you the patient like to join our mailing list? Yes No

Your Patient's Insurance Information Optional

Primary insurance provider

ID number (Letters and Numbers only)

Secondary insurance provider

ID number (Letters and Numbers only)

Your The Patient's Physician Information Optional

Primary physician

Primary physician's phone (###-###-####)

Referring physician

Referring physician's phone (###-###-####)

Risk Assessment

Reproductive System Health

Do you have difficulties with erections and/or ejaculation? * No Yes N/A

Please describe *

Has your primary care physician told you that your PSA is elevated? * No Yes

Do you have scrotal swelling and/or pain? * No Yes N/A

Your Patient's Residential Address