Hope Basket Request
You may request a Hope Basket for a cancer patient that lives in DeSoto County, MS or is being treated at a DeSoto County cancer treatment clinic.
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Email *
Your Name *
Patient's First and Last Name *
Gender *
Is the patient over 55? *
Contact phone number for patient or family member *
Patient's Home Address  *
Treatment Clinic (for patients not living in DeSoto County, we will deliver basket to the selected clinic) *
When is your next appointment? *
MM
/
DD
/
YYYY
Type of cancer (if you feel comfortable sharing).       This helps us to create a more personalized basket.
Current Treatment *
Required
What is your race/ethnicity? *
Are there young children in the home? Please list their ages *
How did you hear about DeSoto Hope? *
NO ONE FIGHTS ALONE!
A copy of your responses will be emailed to the address you provided.
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