Popup (Personal Health Manager Kit Form)

Illinois Patients - Sign up for your FREE Cancer Help Kit

This helpful tool is for people with cancer:

Learn about your specific cancer, treatment and side effects.
Organize your cancer information.
Keep track of test results, doctor appointments and medicines.
Identify questions/issues to talk about with your doctors and nurses.

Please complete the information below. One of our cancer specialists will follow-up with you by phone and ask a few more questions to tailor the Cancer Help Kit to your cancer diagnosis.
All information will remain confidential. We will not share your information
with any other person or organization, nor use it for solicitation.

*I am a:	Patient Caregiver Family Member
*Your Name
*Your Email		*Email Verification
*Your Phone		*Phone Verification
*Best Time To Call (8am-5pm CST, M-F)		Okay to leave a message?	Yes No