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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>

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Page last reviewed December 2010
Internet Citation: Tracking and Improving Screening for Colorectal Cancer Intervention: A: Tool 4.b-4 Stool Test Kit Request Card. December 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/final-reports/crctoolkit/crctool4b4.html