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Blood Cancer Resources Request
Please fill out the information below to request tailored information on blood cancer.
Please select your region:
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Atlantic Canada
Ontario
I am:
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Diagnosed with a blood cancer
Caregiver
Family/Friend
Healthcare Provider
The person diagnosed is my:
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Child
Parent
Friend
Family member
Other
Other
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Requestor First Name
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Requestor Last Name
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Requestor Street Address
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Address Line 2
City
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Province
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New Brunswick
Newfoundland
Nova Scotia
Prince Edward Island
Ontario
Postal Code
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Requestor Phone Number
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Requestor Email Address
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Healthcare Hospital/Centre
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Position
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Are you requesting information on behalf of someone diagnosed with a blood cancer?
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Yes
No
Are you requestiong information on behalf of your patient?
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Yes
No
Person living with a blood cancer information
First Name
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Last Name
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Gender
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Male
Female
Non-binary
Prefer not to share
Prefer to self-identify
Birth Date
*
+
Are you over the age of 18?
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Yes
No
Parent/Caregiver First Name
Parent/Caregiver Last Name
Is their address the same as yours?
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Yes
No
Street Address
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Address Line 2
City
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Province
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New Brunswick
Newfoundland & Labrador
Nova Scotia
Prince Edward Island
Ontario
Postal Code
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Phone Number
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Email Address
*