Fill Out the Form Below to Receive Your Angel Pack™

Date(Required)

Patient Name(Required)

First Last

Birthdate(Required)

How many Angel Packs™ are needed?

Child Age(Required)

Relationship to Patient(Required)

Gender

Your response to the question above enables Angel Foundation™ to better serve communities equitably. All responses are kept private and secured and will NOT be used for discriminatory purposes.

Racial/Ethnic Identity

Your response to the question above enables Angel Foundation™ to better serve communities equitably. All responses are kept private and secured and will NOT be used for discriminatory purposes.

Additional Angel Packs™ Needed?

For each additional Angel Pack™ needed, click the ⊕ on the far right to enter an additional request.

Child Age

Relationship to Patient

Gender

Racial/Ethnic Identity

Would you like a Parent Folder?(Required)

Parent Folders include resources that help caregivers understand how to talk to their children about their cancer diagnosis.

Yes

No

Cancer Type and Stage(Required)

Clinic Name and Location(Required)

Additional Information We Should Know

Who is completing this request?(Required)

Patient

Healthcare Provider

Family/Friend on behalf of the patient

HCP Name

First Last

HCP Role

HCP Email

HCP Phone

Family/Friend Name

First Last

Family/Friend Email

Family/Friend Phone

I hereby declare the information on this application is true and correct to the best of my knowledge. I understand that all information reviewed will be kept confidential. In addition, I am aware that Angel Foundation™ will contact me about this form and/or if I indicated I would like to be contacted about programs. By checking the box below and submitting this application I am acknowledging that I am giving permission for Angel Foundation™ to verify my cancer diagnosis with a healthcare provider at my clinic.

IF PATIENT IS COMPLETING REQUEST:

I understand and provide permission

I hereby declare the information provided on this application is true and correct to the best of my knowledge. I understand that all information reviewed will be kept confidential. In addition, the patient is aware that Angel Foundation™ will contact them if there are questions about this form and/or if I indicated they would like to be contacted about programs. By checking the box below and submitting this application you are acknowledging that the patient has given permission for Angel Foundation™ to verify the patient's cancer diagnosis with a healthcare provider at their clinic.

IF HEALTHCARE PROVIDER IS COMPLETING REQUEST

I understand and provide permission

I understand that the information provided on this form will be kept confidential and the patient will only be contacted by Angel Foundation™ if they have indicated they would like to be contacted about programs.

IF FAMILY/FRIEND IS COMPLETING REQUEST ON PATIENT'S BEHALF

I understand and provide permission

Please sign below (by typing your name) to authorize the patient release.(Required)

Fill Out the Form Below to Receive Your Angel Pack™

Angel Pack™ Request Application

How many Angel Packs™ are needed?

Patient Information