Contact Data Form

Reason for Visit*
Name*
First Middle Last
Birth Date*
MM
DD
YYYY
Maiden Name
Gender*
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Cell Phone
School District*
Email*
Marital Status*
Spouse's Name
Are you a minor?*
Parent / Guardian's Name*
Are you currently a student?*
School & Current Grade*
Emergency Contact
Name*
First Last
Other than spouse
Relationship*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Do you have your health care wishes in writing if you are unable to speak for yourself?*
- Yes
- No
Have you named a person who can speak on your behalf?*
- Yes
- No
Have you shared your wishes with that person and your health care provider?*
- Yes
- No
Have you given a copy to the hospital where you will most likely be treated?*
- Yes
- No
Would you like more information?*
- Yes
- No
How did you learn about our agency?*
- ACS
- Brochure
- Center for Women's Health
- Family Member
- Friend / Coworker
- Health Department
- Infusion Center
- Medical Provider
- Mid-Michigan Health Line
- Pardee Cancer Treatment Fund
- Newspaper
- School
- Special Event (Health Fair, Wellness Day, etc.)
- Television
- Other
Please Specify*
Have you ever been a client before?*
- Yes
- No
Would you like to receive our quarterly email newsletter?*
- Yes
- No
Would you like to receive information about our monthly support groups?*
- Yes, via email
- Yes, via USPS
- No

Cancer Services of Midland

Providing personal and compassionate cancer support, education and prevention services to Midland, Clare, and Gladwin counties since 1948.

220 W. Main Street, Suite 105
Midland MI 48640

Phone: (989) 835-4841
Fax: (989) 832-5544

Monday - Friday 8:30 AM - 5:00 PM
Evenings by appointment

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Your donation helps to support hundreds of individuals regain their strength. Visit our Donations Page for more ways to give.

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