Lung Cancer Canada - Lung Cancer Canada

First Name:

Last Name:

Gender:

Male
Female
Non-Binary/non-Conforming
Prefer not to respond

Address:

Address 2:

City:

Province:

Postal Code:

Phone Number:

Email / Adresse courriel:

I am a:

Patient
Care Partner
Other / Autre

If other, please specify / Si autre, merci de préciser :

Languages spoken:

English
French
Mandarin
Cantonese
Punjabi

Others / Autres:

Please list any other languages

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 care partner/receiving treatment

Please tell us about your lung cancer journey:

Please include when you were diagnosed, what type of lung cancer, what stage of lung cancer, if you have any cancer mutations (EGFR, ALK, ROS1, etc), what past treatments you had, and your current treatment.

Is there anything else you would like us to know?:

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