Name *

First Name

Last Name

Are you 45 or over? *

Yes

No, but I am 44

No, I'm younger than 44

Are you up to date on your colorectal screenings? *

Yes

Maybe, I need to check

No

Do you need help finding out if you're due for a screening? *

Yes

No

Unsure

Do you, or someone you know, have (or had) colorectal/bowel/anal cancer, or ulcerative colitis? *

No, I don't know anyone who's had these cancers

Yes, I have personally

Yes, a family member(s)

Yes, a friend(s)

Yes, an acquaintance(s)

Other

Take the pledge *

I pledge to stay up to date with all colorectal cancer screenings