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Patient or family member information.

Cancer is one word that can change your life forever. Fear, anxiety and despair are normal emotions. We’ve been there, and we can help. We are cancer survivors and caregivers, helping others with the philosophy of “I fought this disease, and now I am going to fight it with you!”

Please make an attempt to fill out all of the information below – this information is used to match you with a cancer survivor who had a similar diagnosis and experience. Caregivers are also encouraged to fill out the form so that we can match you with one of our volunteers who has experience in the caregiver role. Information shared with CanCare is confidential and secure.

Patient/family member details

* required fields

Today's date:*

Where did you learn about CanCare?:

Patient.

Family member.

First name:*

Last name:*

Spouse's name (if applicable):

Date of birth:*

Marital status:

S
M
D
W
SO

Children:

Yes
No

Home phone:*

Cell phone:

Office phone:

Email:

Home street address:*

Home city:*

Home state:*

Home zip code:*

Date of diagnosis:

Cancer site/stage:

Metastasis:

Type of cancer treatment:

In hospital:

Yes
No

Name of hospital:

Hospital phone:

Hospital room:

Doctor:

Name of church or congregation:

Reason for referral/topics you might want to discuss:

CanCare will not share your personal information with any other agencies.