Kentucky CancerLink Personal Request Form

Kentucky CancerLink Personal Request Form

Phone: 859-309-1700 Fax: 859-368-8418
Patient Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Zip code*
County*
Email
example@example.com
Race/Ethnicity*
Sex*

MaleFemale
Language Note

English SpeakingSpanish Speaking OnlyOther
Birth Date MMDDYYYY*

MonthDayYear
Date
Last 4 of Social Security Number
Required for those needing a colon/lung cancer screening
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Okay to Leave Messages on Phone*

YesNo
I have Insurance*

YesNo
Primary Insurance*

MedicaidMedicareWellCareOther
Secondary Insurance

MedicaidMedicareWellCareOther
Emergency Contact Name
Emergency Contact Phone
Relationship to Patient
Number In Household*
Annual Household Income*
Smoking History?*

Current SmokerNeverPrevious Smoker
Interested in quitting?

YesNo
I have been diagnosed with cancer

YesNo
I need a Cancer Screening

YesNo
Cancer Diagnosis Information

(If Applicable)
Cancer Type
Date of Cancer Diagnosis MMYYYY

MonthDayYear
Date
Current Stage
Treatment Facility
HOW CAN WE HELP YOU?
Cancer Support Services
Screenings
Do you need a service not listed above?
Unfortunately at the moment our colon program has been paused, this means we are unable to provide colonoscopies to patients. We hope to get this resolved soon and will reopen the portal when the program is running again.

Thank you for your understanding,

Kentucky CancerLink
Should be Empty:

Kentucky CancerLink Personal Request Form

Patient Information

Cancer Diagnosis Information

HOW CAN WE HELP YOU?