Patient Referral Form

We are here to help you and your healthcare team support blood cancer patients. By completing and submitting this form, you represent that you are authorized to share the information below, including the patient's medical information, with Blood Cancer United. Upon receipt, your patient will be contacted by an Information Specialist, a highly trained oncology social worker or nurse, who provides personalized support to patients, caregivers, and families. This service is not a substitute for medical advice. Patients will be encouraged to discuss what they learn with their treatment team. Please contact the Information Resource Center at 1.800.955.4572 with any questions.

Patient Information

Patient's First Name

Patient's Last Name

Street Address

City

States and Territories

ZIP/Postal Code

Patient/Survivor's Date of Birth

Format: mm/dd/yyyy. Determines whether parent/guardian contact information is required.

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Phone Number

Parent/Guardian Email

Parent/Guardian Primary Language

Parent/Guardian: If Other, please specify

Patient Phone Number

Patient Email

Patient Primary Language

Patient: If Other, please specify

If the patient wishes someone else to be contacted on their behalf, please indicate here:

Someone other than the patient may be contacted on their behalf

Preferred Contact First Name

Preferred Contact Last Name

Preferred Contact Phone Number

Relationship to Patient

Does the Preferred Contact Live with the Patient?

Diagnosis Information

Patient/Survivor's Date of Diagnosis

What is the patient/survivor's primary diagnosis?

Please specify type of Lymphoma:

Please specify subtype of Non-Hodgkin Lymphoma:

Please specify type of Leukemia:

Please specify type of Myeloma

Please specify type of Myeloproliferative Neoplasm (MPN):

Patient Demographic Information

Has the patient/survivor ever served on active duty in the U.S. Armed Forces, Military Reserves, or National Guard?

With which race(s) does the patient/survivor identify? (Select all that apply)

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Some Other Race

Prefer Not to Answer

Does the patient/survivor identify as Hispanic, Latino or Spanish origin?

Please specify the patient/survivor's gender identity:

Referral Comments or Additional Information

Healthcare Professional Making the Referral

Healthcare Professional First Name

Healthcare Professional Last Name

Healthcare Facility/Organization

Healthcare Facility/Organization Zip/Postal Code

Work Email

Work Phone Number

This question is to validate that you are a human visitor and to prevent automated spam submissions.

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Patient Referral Form