Cancer Screening Form

We Are Here to Help

Need to Request a Screening?

If you, or someone you know needs to have a cancer screening, please fill out our screening form or call Kentucky CancerLink at 859.309.1700 or toll free 877.597.4655.

We can connect you with a screening program near you!

Office Hours

Monday-Thursday, 8:30am to 5pm EST (Closed on Friday)

We Are Here to Help

Need to Request a Screening?

If you, or someone you know needs to have a cancer screening, please fill out our screening form or call Kentucky CancerLink at 859.309.1700 or toll free 877.597.4655.

We can connect you with a screening program near you!

Office Hours

Monday-Thursday, 8:30am to 5pm EST
(Closed on Friday)

First Name

Last Name

Phone

Street Address

City

State

Zip Code

County

Date of Birth

Do you have health insurance?

Yes No

If yes, what kind?

Estimated Annual Household Income

Number in Household

Consent

I agree to the privacy policy. (Click to Read Policy)

Address

2425 Regency Road, Suite B
Lexington, KY 40503

Email

info@kycancerlink.org

Phone

Office: (859) 309-1700
Toll Free: (877) 597-4655

Need to Request a Screening?

Need to Request a Screening?