Tracking and Improving Screening for Colorectal Cancer Intervention: A

Tool 4.b-4 Stool Test Kit Request Card

REQUEST FOR STOOL TEST KIT

Patient Name <Mail Merge>

I wish to receive a stool test kit. I know that a stool blood test should be performed annually and understand that a positive (abnormal) test result should be followed up with a colonoscopy.

STUDY ID# <Mail Merge>

Side 2:

REQUEST FOR STOOL TEST KIT
[INSERT HERE: RETURN ORGANIZATION NAME AND ADDRESS]

STUDY ID# <Mail Merge>

Return to Document