Support Registration

Please select the support option you would like to register for (you can select both options) *

Monthly online support group
One-to-one peer telephone support

Name *

First

Last

Phone Number *

Email *

Suburb *

State *

Emergency Contact Name & Phone Number

Please choose the option that applies: *

Patient
Carer / Family

Gender of patient *

Male
Female
Other

Please indicate patient age bracket: *

Stage of bladder cancer *

Non muscle invasive
Muscle invasive
Advanced bladder cancer

Location of cancer *

Bladder
Upper tract
Urethra

When were you diagnosed? *

mm/yy

Treatment

Please indicate your treatment plan

> Intravesical (directly into the bladder through catheter)

If other, please specify

> Intravenous chemotherapy

Please specify

> Radical cystectomy

> Immunotherapy

If other, please specify

> Antibody drug conjugate

If other, please specify

> Combination therapy

If other, please specify

> Clinical trial, please specify

What would you like to gain from this support? *

How did you hear about the BEAT Bladder Cancer Support Group?

Please sign (by typing your name) *

Disclaimer
This Support Group accepts no responsibility for information presented at this meeting. Whilst the information is presented in good faith, it may contain information beyond the knowledge of the Support Group and therefore cannot be taken as the opinion of the Support Group. The information presented is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice, or delay in seeking it because of something you have heard or read here.

Confidentiality Agreement
During my membership in the Support Group, I may learn personal and confidential information about individuals who participate or are involved with this Support Group. Whether information is available to me through the Support Group or accidentally, I agree to maintain confidentiality and not reveal information that is not existing public information to any person in the Support Group or outside of the Support Group while a member of the Support Group or at any time in the future when I may no longer be a member of the Support Group. I understand that breaking of this agreement could result in the termination of my membership with the Support Group. I understand that any information pertaining to my health should be reviewed with my physician. Nothing provided herein should be construed as a substitute for professional advice or treatment by a health care professional. Although good faith efforts have been taken to preserve participant confidentiality, no guarantees can be made in this regard nor to information communicated by and between participants in this forum.

Bladder Cancer Support Registration

Treatment