BMT Patient Form

Patient-to-Survivor Form

If you or a loved one is a candidate for a bone marrow, peripheral blood stem cell, or cord blood transplant, we can "link" you with someone who's been through the experience. Survivors and their family members can share valuable information and provide emotional support.

Please give us the following information so we can make an appropriate match. Or, you may phone us at 847.433.3313 or toll-free: 888.597.7674 to describe the type of person with whom you would like to talk. Please note that while a few of our survivors can be accessed by e-mail, most can only be accessed by phone.

IF YOU ARE REQUESTING A LINK ON BEHALF OF ANOTHER PERSON, be certain that person wants a link before you complete this form. Some patients do not want to talk with survivors, and may resent your well-intentioned efforts to put them in touch with one. Please respect your loved one's right to privacy. Do not send us information about another person without his/her knowledge and permission.

Please provide us with information on how we can contact you:
* Indicates a required entry

Name:

Address:

City:

State/Province:

Zip/Postal Code:

Country:

One of the following phone numbers is required

Evening Phone:

Day Phone

* (Same as above)

Fax:

* (I don't have one)

E-Mail:

* (I don't have one)

Are you the patient?

Yes No

If not, what is your relationship to the patient?

(other)

What is the patient's name?

Are you requesting this link for yourself or the patient?

Yourself Patient

What is your age?

What is the patient's age?

What is the patient's gender?

Male Female

Diagnosis: (e.g., leukemia, breast cancer)

What types of transplant are being considered?

autologous
tandem autologous
allogeneic
syngeneic
allogeneic non-myeloablative (mini-transplant)

What will be the source of stem cells?

bone marrow
cord blood
peripheral blood stem cells

If you will receive bone marrow, stem cells or cord blood from a donor, is the donor

related
identical twin
unrelated

Is the donor's HLA type (marrow or stem cell type)

perfect match
mismatch

Name of medical center where patient will have the transplant:

What should we look for in a link for you? Check the 1 or 2 characteristics that are most important to you.

same age as patient
same age as me (if you are not the patient)
same relationship to the patient
same diagnosis
same type of transplant
same transplant center
had small children at home at time of transplant
sex preferred Female Male

Is there anything else you think we should look for when matching you with a survivor?

Click here to send this form to BMT InfoNet now.

We will attempt to match you with a survivor or family member as quickly as possible. If you haven't heard from us in 5 working days, please contact us again. We may be having trouble reaching you. If you need to talk with someone sooner, please phone us at 847.433.3313 or toll-free: 888.597.7674.