Skip to content
New and Emerging Therapies - Montreal
Thank you for taking the time to register for the educational forum 'New and Emerging Therapies - Montreal' on Saturday, May 24, 2014.
*
1.
CONTACT INFORMATION
(Required.)
FIRST NAME
LAST NAME
ADDRESS 1
ADDRESS 2
CITY
PROVINCE
POSTAL CODE
PHONE NUMBER
EMAIL ADDRESS
*
2.
I am a
(Required.)
Patient
Survivor
Caregiver
Supporter
Nurse
Doctor
Student
Other (please specify)
3.
If a Patient, please indicate your diagnosis
Follicular
Mantle cell
Hodgkin
DLBCL
T-cell
CLL
SLL
Burkitt's
I don't know
Other (please specify)
4.
Please indicate your age
5.
How did you hear about this event?
*
6.
How many guests will be accompanying you?
(Required.)
0
1
2
3
7.
Help us improve our events! Please indicate below what you would like to know more about lymphoma or living with lymphoma:
8.
Would you be interested in Lymphoma Canada’s volunteering opportunities? These could include volunteering at an event, performing administrative functions, or being a mentor to others touched by lymphoma.
No thank you.
Yes, please contact me!
