Health Care Provider Request Form - Canadian Cancer Society

Healthcare provider request

1 888 939-3333 | cancer.ca

Please complete and submit this form if your patient and/or their caregiver would like us to contact them to explain our free programs and services.
We will call the patient or caregiver within one week of receiving this form.

If you prefer a fax form please click here

Patient/caregiver information

*Please enter your first name *Please Enter your last name *Please Enter your preferred language *Please enter your email address *Please enter a valid email address

(1111111111 or 111-111-1111 format)

Healthcare provider information

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Note: In accordance with privacy legislation, the personal information collected on this form will only be used by the Canadian Cancer Society to contact the person to offer them information and support services. In order for us to accept this request, you must gain permission from the person. For further information about our services please call 1-888-939-3333.
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Registered charity: 118829803 RR 0001