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FIT Kit Request Form

A FIT Kit tests for colon cancer.  You do the test at home, and it is very easy to use.  Then, you mail it to a lab and they test it for you.

To order a FIT Kit, please complete this form. If you are eligible, you will receive a kit in approximately one week.

If you have any questions, please contact us through our online form or call (716) 858-7376.  Visit Cancer Services Program for more information about our program and the services we provide.

Are you under age 45 years old?
Are you over age 75 years old?
Have you had a colonoscopy in the past 12 months?
Do you have a history of colorectal cancer, crohn’s, or colitis? age 60?
Do you have a parent or sibling with colorectal cancer before age 60?

You are NOT eligible for a FIT Kit at this time. Please contact your doctor to discuss recommended screening options. If you are uninsured, please contact us through our online form or call (716) 858-7376 and ask us for more information about other free services that the Cancer Services Program provides.

How did you hear about this program? (Select all that apply)
Health Insurance (Select all that apply)

I understand the purpose of this screening test and have been given instructions in use of the FIT KIT.

I understand I will receive results of the test and any abnormal results will be reported to my Primary Care Provider.

I authorize Cancer Services Program of Erie County to release information about me as required for insurance coverage and medical care.

I understand that I am responsible for any charges not covered by my insurance.

I understand that, if I am uninsured, the Cancer Services Program will cover the cost of the screening in my behalf.



By checking this box, I acknowledge that I have read and fully understand this policy.