Prostate Screening Appointment

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

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

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

Care Questions

About You

Smoking Status *

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

Patient MRN

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

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

Are you Black/African American? * Yes No

Do you have a known BRCA I/II mutation, a family history of BRCA mutation or other familial syndromes? * Yes No

About Your Family

Do you have a family history of prostate cancer? * Yes No

Are youIs the patient of Ashkenazi Jewish ancestry? * Yes No Unsure

Start
Personal Information
Care Questions
Finish

Your Patient's Residential Address

Personal Information

About You

Contact Methods

Care Questions

About You

About Your Family