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FIT Kit Request Form

Risk Assessment

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

If you answered YES to any of the questions above, then 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.

If you answered NO to all of the questions above, then please complete this form.

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.