JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Lung Cancer Materials Request Form
Thank you for requesting educational materials from Lung Cancer Initiative to share with your lung cancer patients! Please fill out this form to request materials, and email info at
info@lungcancerinitiative.org
with any questions. We will reach out via email when we have mailed the requested materials.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your answer
First Name
*
Your answer
Last Name
*
Your answer
Name of Business
Please share the cancer center or healthcare facility where you work.
Your answer
Shipping Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
How do you plan to distribute materials?
*
Your answer
Comprehensive Biomarker Testing Rack Card:
*
None
10
25
50
Other:
Required
Provider Screening Flyer
*
None
10
25
50
Other:
Required
Clinical Trials Rack Card:
*
None
10
25
50
Other:
Required
Lung Cancer Screening Risk Assessment Tool
*
None
10
25
50
Other:
Required
Lung Cancer Fact Sheet:
*
None
10
25
50
Other:
Required
Lung Cancer Patient Journal:
*
None
10
25
50
Other:
Required
Lung Cancer Myths Bookmark:
*
None
10
25
50
Other:
Required
Complete folders with all LCI materials to share with newly diagnosed lung cancer patients:
*
None
10
25
50
Other:
Required
Questions or comments:
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Lung Cancer Initiative of North Carolina.
Report Abuse
Forms
