First Connection Request Form

Patti Robinson Kaufmann First Connection Program
Online Request Form

First Name *

Last Name *

Address 1 *

Address 2

City *

State *

Zip/Postal Code *

Please note, requests can only be accommodated for individuals who live in the US or Canada.

Email Address

Phone Number *

Date of Birth * +

With which race(s) do you identify? (Select all that apply) *

Do you identify as Hispanic, Latino or Spanish origin? *

Yes

No

Prefer not to answer

Please specify your gender. *

Female

Male

Another gender

Prefer not to answer

Primary language? *

Have you ever served on active duty in the U.S. Armed Forces, Military Reserves, or National Guard? *

Yes

No

Prefer not to answer

Disease of Interest *

Leukemia Disease Type

Other Disease Type

Myeloproliferative Neoplasms Disease Type

Lymphoma Disease Type

NHL Subtype

I am a *

Date of Diagnosis

The best time to reach me is

Comments

0/255 characters

Are you a Healthcare Professional making the referral? *

Yes

No

First Name *

Last Name *

Healthcare Professional Discipline *

Institution *

Institution street address

Institution address line 2

Institution City *

Institution State *

Institution Zip Code *

Phone Number *

Email Address *

The Leukemia & Lymphoma Society (LLS) is the world's largest voluntary health organization dedicated to funding blood cancer research, education, and patient services.
LLS's mission: Cure blood cancer and improve the quality of life of all patients and their families.

Need Help? Contact us

infocenter@lls.org

(800) 955-4572

For general information about LLS First Connection program and other support resources, please visit: https://www.lls.org/support-resources/peer-peer-support or https://www.lls.org/support-resources

Patti Robinson Kaufmann First Connection ProgramOnline Request Form

Patti Robinson Kaufmann First Connection Program
Online Request Form