Become a Client

Our programs and services are available:
  • To anyone in our service area who has been diagnosed with any type of cancer, as well as their families
  • At no cost
  • Regardless of insurance coverage

Become a Client

If you or a loved one has been diagnosed with cancer, we can help.

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*:

County*:

Primary Phone*:
Type:
Secondary Phone:
Type:

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:

Email Address:

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

Tell us more about your situation

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.

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