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 support to cancer patients and caregivers in our community.

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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