Patient Intake Form

Surname

First Name

DOB (DD-MMM-YYYY)

Phone Number

Primary Email

Country

Home Address

City

Province / State

Postal Code

Name of Family Doctor (BC residents only)

Date bladder cancer diagnosis (DD-MMM-YYYY)

Treatment for bladder cancer

Date of treatment (DD-MMM-YYYY)

Modules interested in attending: Modules interested in attending: Module 1 - Introduction to Invasive Bladder Cancer and Primary Treatment Options Module 2 - Managing the Impact of Bladder Cancer Treatments on Sexual Function and Intimacy Module 3 - Movement & Exercise for Bladder Cancer Patients Module 4 - Wound, Ostomy and Continence Care Module 5 - Pelvic Floor Physiotherapy in Patients with Neo-Bladder and Bowel Management Module 6 - Counselling Services Module 7 - Metastatic Disease Management Module 8 - Nutrition for Bladder Cancer Patients

How did you hear about the BCSC Program? How did you hear about the BCSC Program? Physician (please specify name below) Online search Friend Other (please specify below)

Name of physician or other referral source (if applicable)

I’d like to receive email from the BCSC Program, which may include newsletters, program updates, and other notifications. I’d like to receive email from the BCSC Program, which may include newsletters, program updates, and other notifications. Yes No