Client Application Form Client Application Form CommentsThis field is for validation purposes and should be left unchanged.Name(Required) First Last Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email(Required) PhoneDate of Birth MM slash DD slash YYYY Type of CancerDate of Diagnosis MM slash DD slash YYYY Oncology PhysicianOncologist's PhoneOncologist's Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Patient Navigator/Case Worker First Last PhoneWhat type of treatment are you receiving? Chemo Radiation Other Where are you receiving treatment?Medical FacilityAre you receiving any other assistance?(Required) Yes No If yes, from what organization?Does client have? Medicare Medicaid SSI/SSDI Disability Pension Unemployment Income Veteran Employer Insurance None Other Is there any other authorized person that we may contact regarding your care?(Required) Yes No If so, who? First Last Consent(Required) I do hereby authorize Danville-Pittsylvania Cancer Association, INc. its employees and/or volunteers to contact my physicians, medical facilities, and pharmacies to confirm my cancer related needs. I certify that all of my information is true and complete to the best of my knowledge. I understand that DPCA may revoke my services at any time. Ii will notify DPCA if any of my information changes. Any act of fraud will result in immediate suspension of services and may result in civil action or criminal prosecution. This release is in accordance with any and all healthcare laws.Statistical QuestionnaireUsed for grant purposes only.Total amount of household income:Ethnicity White African American Hispanic/Latino Native American/American Indian Asian/Pacific Islander Other Gender Male Female Number of people in householdIncluding dependentsPlease enter a number greater than or equal to 1.
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