First Connection Request Form

The Patti Robinson Kaufmann First Connection Program connects patients, caregivers and parents over the phone with individuals who have personally experienced the challenges of dealing with a diagnosis of Leukemia, Hodgkin Lymphoma, Non Hodgkin Lymphoma, Myeloma or Myelodysplastic Syndrome.
 
If any patient or family member is interested in speaking to a First Connection Volunteer by phone, please complete the form below.
Patient confidentiality agreement:
To insure patient privacy protection as part of the Health Insurance Portability and Accountability Act (HIPAA), & to provide patients with control over what personal information is used & disclosed, the person submitting this request have been granted the approval of the patient and have agreed to have the above information released to The Leukemia & Lymphoma Society.
 
* Indicates Response Required