Colorectal Cancer Screening Program Interest Form

Colorectal cancer is the third most common cancer in the United States. Colorectal cancer includes cancer of the colon, or intestines, and the rectum. Colon cancer is very treatable when it is found early.


If you are 45 years of age or older, you should be screened for Colorectal Cancer.


If you have certain risk factors you may need to be screened earlier.

To qualify for the colorectal cancer screening program at no cost you must:

  • Be a Carroll County resident
  • Income eligible
  • Uninsured or underinsured
  • Age 45 or over unless you have family / personal history of colorectal cancer or symptoms

Please fill out this form and a staff member will respond back to you within 72 hours.

Sign in to Google to save your progress. Learn more
First Name
Last Name
Street address
City or town
State
Zip code
Date of birth
MM
/
DD
/
YYYY
Telephone number
Email address
Best time to be reached
Clear selection
Primary language
Do you require an interpreter?
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of State of Maryland. Report Abuse
Google Forms