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Lung Cancer Buddy Support Request Form

We understand that navigating lung cancer can be challenging, and having a supportive buddy can make a significant difference. Please fill out the form below to request a buddy who can offer support, share experiences, and help guide you through this journey.

Personal Information

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Enter Full Name *

Date of Birth

Gender *

Email id *

Enter Phone No. *

Information Enter regarding

Medical Information

Diagnosis Date *

Current Stage of Lung Cancer *

Treatment Plan *

Buddy Support Preferences

Preferred Buddy Characteristics: (Select all that apply) *

Experience with Similar Stage
Understanding of Family/Support Issues
Others
Experience with Specific Treatments
Open to Online or In-Person Meetings

Type of Support Needed: (Select all that apply)

Emotional Support
Assistance with Appointment Scheduling
Others
Information about Treatments
Help with Managing Side Effects

Availability

Preferred Communication Method: (Select all that apply) *

Phone Calls
Video Calls
Email
Others

Best Times for Contact: *

Additional Information

Is there anything else you would like us to know about your situation or preferences?

Consent

I consent to the use of my personal information for the purpose of connecting with a buddy support person. (Privacy Policy Link) *

I agree to receive communications regarding buddy support from this website. *

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+ 91 73040 14717
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4/19, Kondaji Chawl, V.L
Pednekar Marg,
Near Tata Memorial Hospital,
Parel, Mumbai 400012