Skip to main content

Coronavirus (COVID-19): Latest Updates | Visitation PoliciesVisitation PoliciesVisitation PoliciesVisitation PoliciesVisitation Policies | COVID-19 Testing | Vaccine InformationVaccine InformationVaccine Information

menu

Center for Community Health & Prevention

Cancer Services Program of the Finger Lakes Region

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.

widget-4bd0b270-354

 
place field "FullName" below

Patient Information

place field "PatientDateOfBirth" below
 
place field "CountyOfResidence" below
place field "PhoneNumber" below
place field "Email" below
place field "Insurance" below
place field "HelpWith" below