Prostate Screening Appointment Request: EDDY Mobile Screening Center

Please complete the form below to determine if you are eligible for the Roswell Park prostate cancer early detection clinic on the EDDY Mobile Screening Center.

If you have any questions regarding this form, please call 1-800-ROSWELL (1-800-767-9355).

Fields marked with an asterisk * are required.

Personal Information

About You

Contact Methods

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.

May we leave a message if you're unable to answer? *

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

Care Questions

At which location would you prefer your screening appointment?  *

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

Are you Is the patient currently a Roswell Park patient? *
Are you currently a patient of our Genitourinary (GU) Cancer Center?  *
Have you had a PSA test before?  *
When was your last PSA test?  *