URMC / Center for Community Health & Prevention / Community-Based Programs / Cancer Services Program of the Finger Lakes Region (CSP-FLR) / Self-Referral Form

Self-Referral Form

The Cancer Services Program offers FREE breast, cervical, and colorectal cancer screenings and diagnostic services for eligible individuals without health insurance. Please fill out the below questionnaire and staff will call you back as soon as possible.

Patient Information

Full Name (First, Middle Initial, Last):

Patient Date of Birth:

Today

County of Residence:

Phone Number (Area Code - XXX - XXXX):

( ) -

Email:

Do you have insurance?:

What are you looking for help with?: