Lung Cancer Canada - Lung Cancer Canada

First Name:

Last Name:

Age:

Gender:

Male
Female

Address:

Address 2:

City:

Province/State:

Postal Code:

Country:

Phone Number:

Email:

I am a:

Patient
Caregiver
Other

If other, please specify:

I am seeking:

to provide peer to peer support to others
to receive peer to peer support from a mentor

Seeking support for:

General Support
Clinical Trials
Treatment Information
Other

Check all that apply

If other, please specify:

Availability:

Phone
Email
Both

Languages spoken:

English
French
Mandarin
German
Italian

Others:

Please list any other languages

Diagnosis Date:

Age at Diagnosis:

Type of Lung Cancer:

Stage at Diagnosis:

Current Stage:

Gene Mutations:

EGFR
ALK
PDL 1 Expression
Other

If other, please specify:

Previous Treatment:

Surgery
Chemotherapy
Radiation
Targeted Therapy
Immunotherapy
None

Please List:

If checked, please list names of all previous chemo, targeted and immunotherapy drugs.

Current Treatment:

Surgery
Chemotherapy
Radiation
Targeted Therapy
Immunotherapy
None

Please List:

If checked, please list names of all previous chemo, targeted and immunotherapy drugs.

Experience with:

Obtaining a second opinion
Managing financial implications of cancer
Being a parent to young children while on treatment
Clinical trials
Alternative therapies
Working while being a caregiver/receiving treatment

Is there anything else you would like us to know:

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Peer-To-Peer

Peer to Peer Support Request Form