BHFA Screening Assistance Application

By adding my name to the box below, I consent and authorize the Colorectal Cancer Alliance to contact my physician listed below to confirm my scheduled appointment

Gastroenteroligist's complete name

Gastroenteroligist's complete phone number

Gastroenteroligist's complete Mailing Address

Is this application being completed by or for a colon or rectal cancer patient who is currently in treatment?

YesNo

This application is only for those in need of assistance for colorectal cancer screening. If you are currently in treatment for colon or rectal cancer please refer to the Treatment Assistance application.

I understand

Patient Information

Patient Salutation

Patient First Name

Patient Last Name

Patient Mailing Address

This is the address where the funding will be sent

Patient City

Patient State

Patient Zip Code

Patient Best Contact Number

Family Member Name

Relation to Patient

Patient Email Address

Email address required. Patient Advocate email address cannot be substituted.

Confirm Email Address

Patient Date of Birth

Patient Gender

Patient Ethnicity

If other, please specify

Please answer the following question before continuing on with the rest of the application

ApplicantFamily Member/FriendPatient Advocate/Patient Navigator/Patient Care Professional

Advocate Information

Advocate First Name

Advocate Last Name

Advocate Email

For advocates: email cannot be the same as patient email

Confirm Advocate email

Advocate Organization

Advocate organization Mailing Address

Advocate City

Advocate State

Advocate Zip Code

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