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New and Emerging Therapies - Toronto
Thank you for taking the time to register for the educational forum "New and Emerging Therapies - Toronto" on Saturday, June 7, 2014 at the Hilton Toronto.
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1.
CONTACT INFORMATION
(Required.)
FIRST NAME
LAST NAME
ADDRESS 1
ADDRESS 2
CITY
PROVINCE
POSTAL CODE
PHONE NUMBER
EMAIL ADDRESS
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2.
I am a
(Required.)
Patient/Survivor
Supporter/Caregiver
Healthcare Professional
Student
Other (please specify)
3.
If a Patient, please indicate your diagnosis
Hodgkin
Follicular
Diffuse Large B-Cell
Marginal Zone/MALT
Mantle Cell
CLL/SLL
Burkitt's
Waldenstrom's Macroglobulinemia
Transformed
Peripheral T-Cell
Cutaneous T-Cell
NK-Cell
I don't know
Other Indolent, Aggressive, or T-Cell lymphoma (please specify)
4.
If a Healthcare Professional, please specify.
5.
Please indicate your age
6.
How did you hear about this event?
*
7.
How many guests will be accompanying you?
(Required.)
0
1
2
3
8.
Help us improve our events! Please indicate below what you would like to know more about lymphoma or living with lymphoma:
9.
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!
