CTC Cancer Comfort Kit Order Form
These Kits are meant for any patient diagnosed with cancer in any stage of treatment. The Cancer Comfort Kits will be available to order twice a year. The deadline for the orders will be January 21, 2020. Any questions, please email info@connectthrucancer.org or call the office at 484-301-3047.

*Kits will be mailed out or delivered the week of February 10, 2020.*

Email address *
Contact Name and Title *
Your answer
Contact Phone Number *
Your answer
Hospital or Cancer Center Name *
Your answer
Delivery/Shipping Address (Please Be Specific) *
Your answer
Number of Boxes (Note: 25 Cancer Comfort Kits per Box) *
What department are you ordering these kits for? *
Your answer
How many new patients do you typically see each month? *
Your answer
Is there anyone else at your hospital/cancer center we should contact to offer these Cancer Comfort Kits? *
Your answer
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