Can Do Cancer : What You Need To Know : Enroll

Patient First Name *REQUIRED

Patient Last Name *REQUIRED

Street Address *REQUIRED

Street Address Line 2

City *REQUIRED

State *REQUIRED

Postal/Zip Code *REQUIRED

Phone Number

Email Address *REQUIRED

Type of Breast Cancer

Select one or more of the following services: * *REQUIRED

Dinner on chemotherapy days
Housecleaning
Motivational support

If you selected dinner, please indicate the number of people in your family, including yourself.

Can Do Cancer provide meals to patients through the use of restaurant gift cards. Please provide us with a list of at least eight preferred restaurants that are conveniently located so that you or a caregiver can pick up dinner on chemotherapy days.

How did you hear about Can Do Cancer?

T-shirt Size *REQUIRED

Birth Date *REQUIRED

Do you have children?

Yes
No

If you have children, please indicate ages (check all that apply):

0-5 years
6-10 years
11-15 years
16-18 years
19 years or older

Preferred Method of Contact *REQUIRED

How often would you like Can Do Cancer to check in on you? *REQUIRED

Can Do Cancer should coordinate my services with *REQUIRED

me
my caregiver

Caregiver First Name

Caregiver Last Name

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Caregiver Email

Caregiver Phone

Cancer Treatment Center *REQUIRED

Oncologist Name *REQUIRED

Oncologist Phone *REQUIRED

Treatment Schedule *REQUIRED

I grant Can Do Cancer permission to contact my oncologist to obtain my treatment schedule.