Patient Enrollment Form - Peer Partners Program
Please complete this enrollment form if you are interested in being matched with a Peer Partner. Once you complete the form, click the submit button at the bottom.
CONTACT INFORMATION:
First name:
*
Last name:
*
Middle Initial:
Title:
Choose
Dr.
Mr.
Mrs.
Ms.
Nickname:
Home phone:
*
OK to call me here
Work phone:
OK to call me here
Cell phone:
*
OK to call me here
Email address:
*
*
How did you hear about the program?:
Another Patient
Family Member/Caregiver
Flyer/Poster
Nurse
Oncologist
Other
Patient & Family Resource Center
Social Worker
Support Group
Winship Volunteer
Winship Website
1
2
First name:
First name:
Last name:
Last name:
Middle name:
Middle name:
Title:
Choose
Dr.
Mr.
Mrs.
Ms.
Title:
Choose
Dr.
Mr.
Mrs.
Ms.
Street 1:
Street 1:
Street 2:
Street 2:
Street 3:
Street 3:
City:
City:
State:
Choose
GA
State:
Choose
GA
Zip:
Zip:
Home phone:
OK to call here
Home phone:
OK to call here
Work phone:
OK to call here
Work phone:
OK to call here
Cell phone:
Cell phone:
Email address:
Email address:
Relationship:
Choose
Co-worker
Daughter
Father
Friend
Mother
Neighbor
Other
Partner
Sibling
Son
Spouse
Supervisor
Relationship:
Choose
Co-worker
Daughter
Father
Friend
Mother
Neighbor
Other
Partner
Sibling
Son
Spouse
Supervisor
Contacted:
Choose
No
Yes
Contacted:
Choose
No
Yes
MEDICAL INFORMATION;
If you are a caregiver, please provide medical information pertaining to the person you cared for.
Date of birth:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
*
Age:
*
Gender:
Choose
Female
Male
*
Applicant Type:
Choose
Caregiver
Family Member
Patient
*
Ethnicity:
Choose
African-American or Black
Asian or Pacific Islander
Bi/Multi-Racial
Caucasian or White
Hispanic/Latino
Native American or Alaska Native
Other
Religious Affiliation:
Date of Initial Diagnosis:
*
Physician's Name:
*
Current Treatment Receiving:
*
Site of Primary Cancer:
*
If other location, please specify:
*
Type of Cancer or Other Diagnosis:
Bone Marrow
Brain
Breast
Caregiver, Not Patient
Cervical
Colon
Head & Neck
Kidney
Leukemia
Liver
Lung
Lymphoma
Melanoma
Myeloma
Oral
Other Cancer/Diagnosis
Ovarian
Pancreatic
Prostate
Sarcoma
Stomach
Testicular
Thyroid
Vaginal
*
Where do/did you receive treatment?:
Northeast Georgia Cancer Center
Other Location
Winship - Clifton Campus
Winship - Midtown Campus: Crawford Long
*
Please indicate all prior treatments::
BMT
Chemotherapy
Clinical Trial
Oral Medication
Other
Radiation
Surgery
Do you speak another language?:
Chinese
French
German
Hindi
Korean
Not Applicable
Other
Spanish
*
Has your cancer metastasized?:
No
Yes
*
New Diagnosis?:
No
Yes
*
Recurrence:
No
Yes
*
Assignment Preference:
Peer Partner - Patient [Winship - Buford]
Peer Partner - Patient [Winship - Clifton]
Peer Partner - Patient [Winship - Emory Proton Therapy Center]
Peer Partner - Patient [Winship - Johns Creek]
Peer Partner - Patient [Winship - Midtown]
Peer Partner - Patient [Winship - St. Joseph's]
Peer Partner - Volunteer [Winship - Buford]
Peer Partner - Volunteer [Winship - Clifton]
Peer Partner - Volunteer [Winship - Emory Proton Therapy Center]
Peer Partner - Volunteer [Winship - Johns Creek]
Peer Partner - Volunteer [Winship - Midtown]
Peer Partner - Volunteer [Winship - St. Joseph's]
Please list the items that you are most concerned with and would like to discuss with a Peer Partner.
LIABILITY STATEMENT & CONFIDENTIALITY STATEMENT:
LIABILITY STATEMENT:
Under the Health Insurance Portability and Accountability Act (HIPAA) law, we are required to have your signed consent to participate as a peer volunteer which includes, but is not limited to, your consent to share your personal contact information. By signing this form, you are providing consent for your personal information to be shared in the peer to peer program.
I give you permission to share my personal information which includes, but is not limited to, health information as well as contact information as a part of the Peer Partners program.
I hereby release and forever discharge Emory University, Emory Healthcare, Inc, The Emory Clinic and Emory Winship Cancer Institute and its employees, officers, agents and volunteers from any liability now or in the future arising from my voluntary participation in and/or benefit from this peer support program.
I hereby release and forever discharge Emory University, Emory Healthcare, Inc, The Emory Clinic and Emory Winship Cancer Institute and its employees, officers, agents and volunteers from any claims, demands and causes of action arising from my participation in and/or benefit from this peer support program.
I hereby affirm that I am over the age of eighteen (18) and I have read and fully understand the above and agree to be legally bound by it.
CONFIDENTIALITY STATEMENT:
I agree to keep confidential all such information, whether verbal, written, or computerized, which I learn in the course of my participation in the Peer Partner Program at Winship Cancer Institute of Emory University. I understand and certify that the use of my elctronic signature or digital signature to authenicate documents is the equivalent of my handwritten signature on the documents.
I Agree
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