Response Form

Please select a response
- Yes. Please send me a Kit
- Opt-Out
- I've already been screened
Please provide an address where we should mail your kit. Kits are mailed in a unmarked envelope via USPS first class letter mail. Please ensure kits are returned prior to April 30th 2019.
Name
First Last
Address*
Street Address Address Line 2 City State Zip Code
Phone Number*
You are choosing to Opt-out from receiving a screening kit for the this years colon cancer screening campaign. Once you make this selection, it can not be undone .
If you would like to speak with a representative regarding this decision, you may call us at 1-855-542-6566.
Method of screening
Please only select this option, if you have already received your colon cancer screening. If you intend to get one at a future time, please select Opt-Out.
Member ID

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Get support on the phone
Mon-Fri | 8am to 5pm

ColonCancerScreeningKit.com
A ColonoscopyAssist Initiative
2100 Valley View Ln,
Suite #490,
Farmers Branch, TX 75234

Phone	: (855) 542-6566
Fax	: (847) 984-1164

Hours : Mon-Fri 8-5pm (CST)