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Halifax Lymphoma Patient and Caregiver Support Meeting - June 18, 2018
Thank you for taking the time to register for the Halifax Lymphoma Patient and Caregiver Support Meeting on June 18, 2018
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1.
Contact Information
(Required.)
Full Name:
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Address 1:
City/Town:
ZIP/Postal Code:
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Email Address:
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Phone Number:
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2.
Please indicate your interest in lymphoma (you may select all that apply).
(Required.)
I have Hodgkin lymphoma
I have Follicular lymphoma
I have Diffuse Large B-Cell lymphoma
I have Marginal Zone/MALT lymphoma
I have Mantle Cell lymphoma
I have CLL/SLL lymphoma
I have Burkitt's lymphoma
I have Waldenstrom's Macroglobulinemia lymphoma
I have Transformed lymphoma
I have Peripheral T-Cell lymphoma
I have Cutaneous T-Cell lymphoma
I have NK-Cell lymphoma
I have another type of lymphoma, not listed here
I do not know what kind of lymphoma I have
I know someone who has lymphoma
Other
Other (please specify)
3.
Will you be bringing a guest?
Yes
No
Not Sure
