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Empowering Lung Cancer Patients
Empowering Lung Cancer Patients

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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How did you find out about the Buddy Program?

Year of Birth (Patient)

Medical Information

Buddy Support Preferences

Preferred Buddy Characteristics: (Select all that apply)
Type of Support Needed: (Select all that apply)

Additional Information

Consent

I consent to the use of my personal information to connect with a Buddy Support Person. (Privacy Policy)

I consent to the use of my personal information for the purpose of connecting with a Buddy Support Person. (Privacy Policy Link)

I voluntarily agree to participate in the Buddy Program for emotional and peer support only. I understand that the Buddy Supporter is not a medical professional and that no medical advice or treatment consultation will be provided.

I agree that no money, fee, gift, or financial transaction will be involved for this support service. I also understand that Lung Connect India Foundation is only facilitating the connection and shall not be responsible or liable for any issues arising from the Buddy Program interactions.

I agree

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