This form is for Healthcare Professionals who wish to refer their patients/clients.
If you are not a Healthcare Professional, please click here

 

PLEASE ENSURE THAT YOU FILL IN ALL OF THE REQUESTED INFORMATION!

Failure to complete the form in its entirety will result in delays or an inability to get your patients the services you are seeking on their behalf.

Requester Information

Name of Organization

Name of Individual Completing This Form

Phone

Email

Do you want CanCare follow up? Select... No Yes

Have you referred someone to us before? Select... No Yes

Is the person being referred expecting a call from CanCare? Select ... No Yes

Client Information

Client is a...

Patient

Family member / caregiver

Client First Name

Client Last Name

Client Email

Client Date of Birth

Month January February March April May June July August September October November December

Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Year 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040

The Patient is my Select... Aunt/Uncle Brother Brother-in-law Daugher-in-law Daughter Extended Family Father Father-in-law Friend Grandfather Grandmother Husband Mother Mother-in-law Same Sex Partner Sister Sister-in-law Son Son-in-law Wife Other (not listed)

Other Patient Relationship

The Patient's age is Select... child infant teenager 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 91 92 93 94 95 96 97 98 99

The Patient's gender is Select... Female Male Not Specified

Are you open to receiving support from a volunteer whose loved one did not survive? Select ... No Yes

Country Select ... AFGHANISTAN ALAND ISLANDS ALBANIA ALGERIA AMERICAN SAMOA ANDORRA ANGOLA ANGUILLA ANTARCTICA ANTIGUA AND BARBUDA ARGENTINA ARMENIA ARUBA AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA, PLURINATIONAL STATE OF BONAIRE, SINT EUSTATIUS AND SABA BOSNIA AND HERZEGOVINA BOTSWANA BOUVET ISLAND BRAZIL BRITISH INDIAN OCEAN TERRITORY BRUNEI DARUSSALAM BULGARIA BURKINA FASO BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA CHRISTMAS ISLAND COCOS (KEELING) ISLANDS COLOMBIA COMOROS CONGO CONGO, THE DEMOCRATIC REPUBLIC OF THE COOK ISLANDS COSTA RICA COTE D'IVOIRE CROATIA CUBA CURA CYPRUS CZECH REPUBLIC DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA FALKLAND ISLANDS (MALVINAS) FAROE ISLANDS FIJI FINLAND FRANCE FRENCH GUIANA FRENCH POLYNESIA FRENCH SOUTHERN TERRITORIES GABON GAMBIA GEORGIA GERMANY GHANA GIBRALTAR GREECE GREENLAND GRENADA GUADELOUPE GUAM GUATEMALA GUERNSEY GUINEA GUINEA-BISSAU GUYANA HAITI HEARD ISLAND AND MCDONALD ISLANDS HOLY SEE (VATICAN CITY STATE) HONDURAS HONG KONG HUNGARY ICELAND INDIA INDONESIA IRAN, ISLAMIC REPUBLIC OF IRAQ IRELAND ISLE OF MAN ISRAEL ITALY JAMAICA JAPAN JERSEY JORDAN KAZAKHSTAN KENYA KIRIBATI KOREA, DEMOCRATIC PEOPLE'S REPUBLIC OF KOREA, REPUBLIC OF KUWAIT KYRGYZSTAN LAO PEOPLE'S DEMOCRATIC REPUBLIC LATVIA LEBANON LESOTHO LIBERIA LIBYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAO MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MAYOTTE MEXICO MICRONESIA, FEDERATED STATES OF MOLDOVA, REPUBLIC OF MONACO MONGOLIA MONTENEGRO MONTSERRAT MOROCCO MOZAMBIQUE MYANMAR NAMIBIA NAURU NEPAL NETHERLANDS NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NIUE NORFOLK ISLAND NORTHERN MARIANA ISLANDS NORWAY OMAN PAKISTAN PALAU PALESTINIAN TERRITORY, OCCUPIED PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES PITCAIRN POLAND PORTUGAL PUERTO RICO QATAR REUNION ROMANIA RUSSIAN FEDERATION RWANDA SAINT BARTH SAINT HELENA, ASCENSION AND TRISTAN DA CUNHA SAINT KITTS AND NEVIS SAINT LUCIA SAINT MARTIN (FRENCH PART) SAINT PIERRE AND MIQUELON SAINT VINCENT AND THE GRENADINES SAMOA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SENEGAL SERBIA SEYCHELLES SIERRA LEONE SINGAPORE SINT MAARTEN (DUTCH PART) SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDS SOUTH SUDAN SPAIN SRI LANKA SUDAN SURINAME SVALBARD AND JAN MAYEN SWAZILAND SWEDEN SWITZERLAND SYRIAN ARAB REPUBLIC TAIWAN, PROVINCE OF CHINA TAJIKISTAN TANZANIA, UNITED REPUBLIC OF THAILAND TIMOR-LESTE TOGO TOKELAU TONGA TRINIDAD AND TOBAGO TUNISIA TURKEY TURKMENISTAN TURKS AND CAICOS ISLANDS TUVALU UGANDA UKRAINE UNITED ARAB EMIRATES UNITED KINGDOM UNITED STATES UNITED STATES MINOR OUTLYING ISLANDS URUGUAY UZBEKISTAN VANUATU VENEZUELA, BOLIVARIAN REPUBLIC OF VIET NAM VIRGIN ISLANDS, BRITISH VIRGIN ISLANDS, U.S. WALLIS AND FUTUNA WESTERN SAHARA YEMEN ZAMBIA ZIMBABWE

Address

Apt/Ste

City

State Select ... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

County Select state first

Postal Code

Address

Address 2

Address 3

Address 4

Address 5

Client Preferred Phone Number

One phone number is required.

Client Gender Select... Female Male Other Prefer not to answer

Date of diagnosis?

Cancer Type Select ... Adenocarcinoma Anus Bile duct (Liver) Bladder Blood Blood - AML Blood - APL Blood - CLL Blood - CML Bone Bone - Osteosarcoma Brain Breast Breast - Adenocystic Carcinoid Breast - BRCA+ Breast - DCIS Breast - Ductal Breast - Estrogen and/or Progesterone Positive Breast - HER 2+ Breast - In Situ Breast - Inflammatory Breast - Invasive Breast - Lobular Breast - Paget Disease Breast - Triple Negative Breast - Triple Positive Burkitts Lymphoma Cervix Colon Diffuse Large B-Cell Lymphoma Endometrium Esophagus Ewing Sarcoma Eye Follicular Lymphoma Head & Neck Hodgkin's Lymphoma Kidney Larynx Liver Lung Lung - Small Cell & Non Small-Cell Carcinoma Lymphoma - Large B-Cell Lymphoma - Primary Mediastinal Mantle Cell Lymphoma Melanoma Mesothelioma Multiple Myeloma Neuroendocrine Tumor Non-Hodgkin's Lymphoma' Other Ovary Pancreas Papillary Thyroid Pleomorphic Sarcoma (Malignant Fibrous Histiocytoma) Prostate Rectum Sarcoma Skin Spindle Cell Sarcoma Squamous Cell Carcinoma Testicle Throat Thymoma Thyroid Tongue Uterus

Describe other cancer type

Stage of Cancer? Select ... Unsure N/A Stage 0 Stage 1 Stage 2 Stage 3 Stage 4

Treatment BMT / SCT Chemotherapy Hormone Therapy Hospice (no longer seeking treatment) Immunotherapy Lobectomy Ostomy Other Palliative Care Radiation Surgery Surgery - double mastectomy Surgery - lumpectomy Surgery - reconstruction Surgery - single mastectomy To be determined Surgery - resection

Describe other treatment

Reason for Referral or additional information to assist us in making a quality match for your client

Is the patient open to a match with a volunteer with a different type of cancer? Select ... No Yes