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Survivorship Clinic Submission

This survivorship clinic listing is a resource for patients and healthcare providers looking for survivorship care. Please submit your clinic's information using the following survey. All entries will be reviewed prior to being posted.

Please complete the questionnaire as completely as possible to provide patients and healthcare providers the information they need about your clinic. We consider a survivorship clinic one that offers survivors visits with providers who will focus on survivorship issues.

Thank you!

Institution / Health System Name

* must provide value

Who does your clinic serve? (check all that apply)

* must provide value

Adult survivors (diagnosed after age 18)

Adult survivors of childhood cancers (cancer diagnosis before age 18)

Childhood cancer survivors (who are currently under age 18)

Program Name

Program contact person

* must provide value

Program contact person's email address

* must provide value

Program website url

Program location - street address

* must provide value

City

* must provide value

State

* must provide value

Zip Code

* must provide value

Phone number to call for appointments

* must provide value

Phone number for general questions

* must provide value

This clinic can see (check all that apply):

Patients who were NOT treated at this institution.

Patients who were treated at this institution only.

Patients who have completed active treatment.

Patients who are in remission or disease free.

Patients on long-term or maintenance therapy.

Patients with metastatic disease.

Do you see all types of cancer? If not, please specify the cancer diagnoses the clinic will see.
Are there any cancer types you cannot see?

* must provide value

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This survivorship program (check all that apply):

* must provide value

Has individual patient appointments.

Has group sessions on survivorship topics.

Other (please specify)

Specify "Other":

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Patients at this clinic may be seen by (check all that apply):

A physician

A nurse practitioner or physician's assistant

A nurse

A social worker

A nurse navigator

A dietitian

A physical therapist

A specialist in cardiology, endocrinology, or other medical field

Does your institution offer special clinical programs (beyond educational programs or inservices) addressing any of the following survivorship concerns?

Fatigue

Sleep Disturbance

Lymphedema

Fertility Concerns Pre And/or Post Treatment

Psychosocial Concerns / Counseling

Primary Care Specialized In Survivor Care

Chemo-brain (Cognitive Dysfunction)

Cardiac Late Effects

Nutritional Issues

Cancer Or Treatment Related Pain

Neurologic Late Effects (radiculopathy, Plexopathy, Neuropathy, Myopathy, Autonomic Dysfunction)

Sexual Health Issues

Speech And Swallowing

Bladder Dysfunction / Pelvic Rehabilitation

Smoking Cessation

Diarrhea / Bowel Dysfunction

Is there any other information you would like to include?

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To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.