Survey Form

Your Name (*)

Are you a patient or a caregiver (*)

Telephone Number (*)

Gender (*)

Age (*)

Language preference (*)

Preferred method of contact (*)

Best time to call

What is your diagnosis : (*)

What treatments have you received or will you receive (*)

What is the name of your oncologist and/or physician (*)

What support services are you interested in (*)

Are you interested in receiving notices about Save Your Skin Survivorship Webinars (*)
 Yes No

May we leave a phone message at your number identifying ourselves as the Save Your Skin Foundation? (*)
 Yes No

I give permission to be contacted (*)
 Yes No

I give permission to receive newsletters from the Save Your Skin Foundation (*)
 Yes No