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NEW - Check for a Match

Knowing that there is someone to talk to provides instant relief and comfort to a patient. As a professional, you can check for a potential match prior to referring your patient to us. By pre-checking, you can be confident your referral will result in a match that truly meets your patients' specific needs.

Complete the form below, or call 800-552-4366, to check for a match. We will respond to your request within the next business day.

Type of match
Who is match for?		Patient Family Other
If match is for a family member, relationship to patient:
Person to be matched
Name:
Age:		Sex:	Male Female
Person requesting match
Name:
Phone:		E-mail:
Best date/time for Cancer Hope Network to contact you:
Diagnosis
Cancer type:		Stage:
Date of current diagnosis:
Any other information about diagnosis:
Treatment
Chemotherapy:		Start date:
Radiation:		Start date:
Surgery:		Date:
General concerns

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