Survivorship Email Distribution Release

You are a survivor! At Paoli Hospital, we believe it is our responsibility to keep you informed and provide access to specific survivorship care. This responsibility does not stop with your last treatment... it is ongoing and lifelong.

For this reason, we have created a survivorship email distribution list to help connect you to several key survivorship programs and events. Providing us with your email will enable us to send you updates on research and care, inform you our Center's events such as Survivor Day, and connect you to valuable resources to support your ongoing health.

If you are interested in receiving this information, please complete the form below. You can unsubscribe at any time by contacting our Survivorship Nurse Practitioner at Survivorship@mlhs.org. To protect your privacy, we will not share your email address with other survivors and/or staff, nor third parties.

We are proud and excited to offer you this opportunity, which will empower you throughout your journey in life.

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* 1. First name:

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* 2. Last name:

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* 3. DOB(MM/DD/YYYY):

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* 4. Diagnosis:

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* 5. Email Address:

By my electronic signature below, I authorize Paoli Hospital Cancer Center and its employees to email information on survivorship events, support groups, and information on research opportunities. I understand that I can unsubscribe from participation in this distribution list at any time by contacting the Survivorship Nurse Practitioner, at Survivorship@MLHS.org.

Survivorship Email Distribution Release

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* 1. First name:

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* 2. Last name:

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* 3. DOB(MM/DD/YYYY):

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* 4. Diagnosis:

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* 5. Email Address:

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* 6. Patient/Authorized Representative Signature (type in name to sign:)

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* 7. Confirm email address to sign-up:

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* 8. Date of patient or authorized representative signature (MM/DD/YYYY):