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Patient Services Contact Form
Date
(mm/dd/yyyy)
Contact Information
Name
First Name
Last Name
Email
Confirm Email
Phone
Address
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
How did you hear about Sue's Gift?
Are you a patient/survivor or caregiver?
select one
Patient/Survivor
Caregiver
If you are a caregiver, what is your relationship to the patient?
About Your Diagnosis
Date of Diagnosis
Physician
Type of Gynecologic Cancer
Cervical
Endometrial
Fallopian
Ovarian
Peritoneal
Uterine
Vaginal
Vulvar
Stage
Stage I
Stage IA
Stage IB
Stage IC
Stage II
Stage IIA
Stage IIB
Stage IIC
Stage III
Stage IIIA
Stage IIIB
Stage IIIC
Stage IV
Recurrence
To be determined
Are you currently in treatment?
Yes
No
Checkboxes
Are you interested in receiving information about any of the following Patient Services?
Caregiver Support
Financial Assistance
Individual Support
Patient Services Volunteer Opportunities (inc. PS Committee or Financial Assistance Task Force)
Virtual Gynecologic Cancer Support Group
Virtual Integrative Therapy Classes
Woman to Woman (For patients: "I'd like to connect with another survivor with my diagnosis.")
Woman to Woman (For survivors who are one year post-treatment: "I'd like to provide peer support to a new patient because I wish I'd had someone to talk with when I went through this." Training is required. )
Additional Comments
Consent to Contact
May we contact you?
select one
Yes
No
What is the best way to reach you?
Phone
Email
May we add you to our newsletter/email list?
Yes
No
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.
Confidentiality Agreement
*
select one
Yes, I agree.
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:
Healthcare provider name and credentials
Healthcare provider organization
Healthcare provider email
Healthcare provider phone
Healthcare provider comments