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Woman to Woman Patient Application

Thank you for your interest in Woman to Woman (W2W), a partnership program between the Ovarian Cancer Research Alliance, Sue's Gift and your medical team. The Woman to Woman program matches women with a gynecologic cancer diagnosis with someone who has completed treatment. The knowledge and insight of a survivor who had the same diagnosis and similar experience can alleviate feelings of isolation and the unknown.

To facilitate the best possible match, please complete the following information. We will be in touch with you once we receive this form to set up a brief 1:1 program overview prior to matching you with a survivor.


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Demographic Information

First Name
Last Name




Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Medical Information








Additional information to assist with facilitating the best match:







Are you interested in receiving information about any of the following Patient Services?

Confidentiality Agreement
To ensure privacy protection as part of the Health Insurance Portability and Accountability Act (HIPAA) and to provide indivicuals with control over what personal information is used and disclosed, I agree to provide the above information to Sue's Gift.
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Questions?
Please contact Sherry Martin, LCSW, Patient Services Director, at 719-422-9964 or sherry@suesgift.org.
Healthcare Referral
If you are a healthcare professional submitting this information on behalf of a patient, please complete the following: