Franklin Central School District PO Box 888
Franklin, NY 13775 Ph: 607-829-3551 Fax: 607-829-2101

CANCER SCREENING FORM

I am submitting the Cancer Screening form as I have undergone a cancer screening procedure.

Date of Appointment:

Time of Appointment:

____________________________________________

___________________________________________

Healthcare Provider (Physician, Medical Office, Imaging Centers, Hospitals, etc.)

Name:

Address:

_________________________________________________

_________________________________________________

_________________________________________________

Healthcare Provider Signature: ____________________________________

Date:	____________________________________

I affirm that the statements made on this form are true and correct under penalty of law.

_____________________________________________________ Employee Signature	Print Name

________________ Date