Triage Cancer Materials Request Form
Please complete the following request form to order educational materials from Triage Cancer. Please allow for 2 weeks for materials to arrive. For questions, please email info@TriageCancer.org.

Please note: the materials listed below are the ones currently available for shipping. You can also print copies of these materials from our website. To see the full library of resources visit http://triagecancer.org/resources.
First Name *
Your answer
Last Name *
Your answer
Hospital/Organization *
Your answer
Shipping Address: Street Number and Name *
Your answer
City *
Your answer
State *
Your answer
Zip code *
Your answer
Email *
Your answer
Phone Number (for questions) *
Your answer
Quick Guides - Please identify the quantity that you are requesting, by topic. If you would like custom amounts, please note amounts below.
25
50
Other (please indicate # below)
Access to Medical Records
ADA & Reasonable Accommodations
Appeals: Individual & Employer Plans
Caregiving
Chemo Brain
Clinical Trials
COBRA
Crowdfunding
Disability Insurance
Disclosure, Privacy & Medical Certification
Estate Planning
Fertility Preservation
FMLA Expanded
Health Insurance Basics
Health Insurance Options
How FMLA Works With Other Benefits
Legal Assistance
Life Insurance
Medicare 2020
Medicare Basics
Medicare Savings Program
Medigap
Timing of SSDI & Medicare Benefits
Custom amount requested
Your answer
Check Lists - Please identify the quantity that you are requesting, by topic. If you would like custom amounts, please note amounts below.
25
50
Other (please indicate # below)
Minimize Financial Toxicity
Reasonable Accommodations
Getting Organized
Custom amount requested
Your answer
Spanish Quick Guides & Check Lists - Please identify the quantity that you are requesting, by topic. If you would like custom amounts, please note amounts below.
25
50
Other (please indicate # below)
Check List - Reasonable Accommodations
COBRA
Disability Insurance
Estate Planning
FMLA Expanded
Health Insurance Options
Medicare
Custom amount requested
Your answer
Flyers - Please identify the quantity that you are requesting, by topic. If you would like custom amounts, please note amounts below.
25
50
100
Other (please indicate # below)
Information Sheet / How Triage Cancer Can Help
Webinar Flyer
Conference Postcard
Custom amount requested
Your answer
Postcards - Please identify the quantity that you are requesting below.
25
50
100
CancerFinances.org
Animated Videos (English & Spanish)
Custom amount requested
Your answer
Drug Discount Cards - Please identify the quantity that you are requesting below.
25
50
100
Drug Discount Cards
Custom amount requested
Your answer
Submit
Never submit passwords through Google Forms.
GoogleForms
This form was created inside of Triage Cancer.