Free Colon Cancer Screening Kit
Show pharmacist once complete to receive your kit
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
FOBT or FIT
Kit Results
Gender
*
Please Select
Male
Female
Email
We will email you to remind you to send in your kit or to see if you would like to participate in future years.
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Phone Number
*
We may send text reminders to return the screening kit.
Format: (000) 000-0000.
What pharmacy are you visiting today?
*
Bakers
HyVee
USave
Walgreens
Please list the specific location of the pharmacy:
Example: 72nd and Dodge
Name of Primary Care Clinic
City/State of Primary Care Clinic
Your Signature:
Submit
Should be Empty: