Colon Cancer Screening Test Request Form

Question Title

* 1. What is your name?

Question Title

* 2. What is your date of birth?

Date of Birth

Date

Question Title

* 3. Where should HealthPoint mail your colon cancer screening test?

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Question Title

* 4. Health History Disclaimer: Annual, at-home tests are an effective way to detect colon cancer. However, depending on your personal and family health history, other forms of colon cancer screening may be more appropriate. If you have any of the following, you are at an increased risk for colon cancer and should talk to your medical provider about which screening option is best for you:

A personal history of colorectal cancer or adenomatous polyps

A personal history of inflammatory bowel disease (ulcerative colitis or Crohn’s disease)

A strong family history of colorectal cancer or polyps

A known family history of a hereditary colorectal cancer syndrome such as familial adenomatous polyposis (FAP) or Lynch syndrome (hereditary non-polyposis colon cancer or HNPCC).

I have read and understood the Health History Disclaimer.

If you would like to discuss other screening options with your medical provider, please call HealthPoint at 425-203-5439 and we will be glad to assist you in making an appointment.