Add Patient To Target Group

Case Status*
- Please call patient to determine status
- Opted In - Mail out kit
- Already Screened
- Declined Screening
- Kit was hand delivered to patient
Name*
First Last
Date of birth*
MM
DD
YYYY
Gender*
- Male
- Female
Address*
Street Address Address Line 2 City State Zip Code
Phone*
Email
Customer Identification Number
An optional ID the campaign manager can enter to easily track requests

Instructions

Successful submission of this form will result in addition of a new patient to this campaign.

Please do not use this form to resend a kit to an existing patient.

CASE STATUS

Every patient added to the campaign must choose from one of the following options :
1) Opt In to receive a screening
2) Decline the screening because they are already screened
3) Decline the screening for another reason

If you have spoken to the patient and already have a response, please enter in the response in the form. If marked as Opted In, a kit will immediately be mailed to the patient. If marked as “Please call patient to determine status”, a representative will call the patient to verify if they would like to participate in the campaign.

Add Patient To Campaign

Add Patient To Target Group

Instructions