Prostate Screening Appointment Request: EDDY Mobile Screening Center

Personal Information

About You

First name *

Last name *

Date of birth * (mm/dd/yyyy)

Contact Methods

Your Patient's Email Address

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

Best time to call

May we say we're calling from Roswell Park? *

Due to HIPAA regulations, Roswell Park will not be able to identify itself to someone other than you or in a voice message, unless you indicate otherwise.

Yes No

May we leave a message if you're unable to answer? * Yes No

Your Patient's Insurance Information Optional
Providing your insurance information will help us schedule your appointment faster.

Primary insurance provider

ID number (Letters and Numbers only)

Care Questions

These details are required to determine if you are eligible for a prostate screening.

Are you Is the patient currently a Roswell Park patient? * Yes No

Patient MRN

Are you currently a patient of our Genitourinary (GU) Cancer Center? * Yes No

Have you had a PSA test before? * Yes No

When was your last PSA test? * Less than 12 months ago More than 12 months ago I am not sure

Your Patient's Residential Address

Personal Information

About You

Contact Methods

Your Patient's Insurance Information OptionalProviding your insurance information will help us schedule your appointment faster.

Care Questions

Your Patient's Insurance Information Optional
Providing your insurance information will help us schedule your appointment faster.