Colon Cancer Screening Test Request Form Question Title * 1. What is your name? Question Title * 2. What is your date of birth? Date of Birth Date Question Title * 3. Where should HealthPoint mail your colon cancer screening test? Address * Address 2 City/Town * State/Province * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code * Question Title * 4. Health History Disclaimer: Annual, at-home tests are an effective way to detect colon cancer. However, depending on your personal and family health history, other forms of colon cancer screening may be more appropriate. If you have any of the following, you are at an increased risk for colon cancer and should talk to your medical provider about which screening option is best for you: A personal history of colorectal cancer or adenomatous polyps A personal history of inflammatory bowel disease (ulcerative colitis or Crohn’s disease) A strong family history of colorectal cancer or polyps A known family history of a hereditary colorectal cancer syndrome such as familial adenomatous polyposis (FAP) or Lynch syndrome (hereditary non-polyposis colon cancer or HNPCC). I have read and understood the Health History Disclaimer. If you would like to discuss other screening options with your medical provider, please call HealthPoint at 425-203-5439 and we will be glad to assist you in making an appointment. Mail my test!