Side by side. Every step of the way.

There are two ways to register:

  1. CLICK TO DOWNLOAD THIS FORM, complete it and bring it with you. 
  2. REGISTER ONLINE: Simply fill out the form below.

* = Required

Client Contact Information

First Name*: Last Name*:

Date of Birth:* Year:

Home Address*:

City*: State*: Zip*:


Primary Phone*: Type:
Secondary Phone: Type:

Email Address:

Name of Parent or Guardian if client is under 18:

Cancer Diagnosis*:

Date of Diagnosis: Year:

If this information was completed by someone other than the client:

Your Name:

Relationship to Client:

Phone: Type:

Is the client aware that Cancer Services will be contacting them? Yes No

In submitting this information, I understand that Cancer Services of Northeast Indiana will not release names, addresses, or mailing lists to others without my consent and will use the above information to offer and/or provide services related to the cancer diagnosis to the client and his/her family.

Anti-SPAM: Please check the "I'm not a robot" box below

Clients are eligible to receive:
  • Massage and exercise therapy
  • Transportation assistance
  • Wigs and turbans
  • Nutrition education & supplies
  • Home health supplies
  • Durable medical equipment loans