Re: Cancer

Match Request Form

Re: Cancer provides emotional support through our peer-to-peer matching program for both survivors & family members. If you are interested in being matched with a trained volunteer who has had a similar diagnosis, please fill out the form below.

Who has cancer?

Please check one*
  • I have received a cancer diagnosis
  • My family member has received a cancer diagnosis

Please tell us a little about the diagnosis:

What type of cancer?
  • Adenoid
  • Anal
  • Appendix
  • Bladder
  • Bone
  • Brain - glioblastoma
  • Brain - meningioma
  • Brain - unknown type
  • Breast - DCIS
  • Breast - IBC
  • Breast - IDC
  • Breast - ILC
  • Breast - LCIS
  • Breast - unknown type
  • Colon
  • Endometrial
  • Esophageal
  • Head & Neck
  • Kidney
  • Kidney - Wilms tumor
  • Leiomyosarcoma
  • Leukemia - ALL
  • Leukemia - AML
  • Leukemia - CLL
  • Leukemia - CML
  • Leukemia - unknown type
  • Lymphoma - Hodgkin's
  • Lymphoma - Non-Hodgkin's
  • Melanoma
  • Multiple Myeloma
  • Ovarian
  • Pancreatic
  • Prostate
  • Rhabdomyosarcoma
  • Soft Tissue Sarcoma
  • Testicular
  • Throat
  • Thyroid
  • Tongue
  • Urachal
  • Uterine
  • RARE CANCER
Diagnosis Date
Treatment
  • Chemo - infusion
  • Chemo - oral
  • Radiation
  • Surgery
  • Amputation
  • Feeding tube
  • Bone marrow transplant
  • Stem cell replacement

If your family member is the one with cancer, please answer the following:

The family member is my...
  • Aunt
  • Boyfriend
  • Brother
  • Brother-in-law
  • Cousin
  • Daughter
  • Father
  • Father-in-law
  • Fiance
  • Friend
  • Gay Partner
  • Girlfriend
  • Grandfather
  • Grandmother
  • Husband
  • Mother
  • Mother-in-law
  • Sister
  • Sister-in-law
  • Son
  • Uncle
  • Wife

Contact Information

Country
State / Province*
Address
City
Email*
Confirm Email*
Phone*
Additional Comments

Security Code

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