Self Referral

If your family physician is performing routine cancer screening for you, you do not need this self-referral form. Please follow up with your family physician if you have questions regarding your personalized cancer screening.

 

Am I A Candidate for the RAAMP Self-Referral for Routine Cancer Screening?

 If you answer yes to any of the questions below, please complete the online form to complete your self-referral.

 

Do I qualify for Colon Cancer Screening?

Are you 50 years of age or older and have never completed a Fecal Occult Blood Test (FOBT) or colonoscopy?

Do you have a first-degree relative that was diagnosed with colon cancer?

Have you been diagnosed with Ulcerative Colitis or Crohn’s Disease?

 

Do I qualify for Breast Cancer Screening?

Are you 50 years of age or older and have never had a mammogram completed?

Do you have a first-degree relative that was diagnosed with breast cancer?

 

Do I qualify for Cervical Cancer Screening?

Are you a female who is 21 years of age or older and it has been >3 years since your last Pap Test?

 

Do I qualify for Ovarian Cancer Screening?

Do you have a first-degree relative that was diagnosed with ovarian cancer?

 

Do I qualify for Prostate Cancer Screening?

Do you have a first-degree relative that was diagnosed with prostate cancer?

 

Do I qualify for Lung Cancer Screening?

Are you between the ages of 55 to 74 years of age, and smoking 1 pack of cigarettes per day for the last 30 years?

 

Do I qualify for Skin Cancer Screening?

Do you have a family history of melanoma? Do you have more than 50 moles on your body? Do you have naturally red or blonde hair and a tendency to freckly easily? Do you have a history of radiation exposure?


* Required

I am requesting an appointment for Routine Cancer Screening for:

Please check one or more of the boxes that you qualify for (see above):

If Applicable:

I have a family history of cancer
(please indicate details below such as age at diagnosis, type of cancer and relation).

WINDSOR PROFESSIONAL CENTRE:
2464 HOWARD AVE, SUITE 202, WINDSOR, ON N8X 3V6
P 519.252.9861 EXT 5 | F 226.216.0643 | E INFO@RAAMP.CA
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