Survivor 2 Survivor for Patients to Fill Out

Please fill out as much information as you feel comfortable giving. The more information we have, the easier it is to make a match for you. If you are filling this out for yourself, you do not need to enter the "Person diagnosed with bladder cancer (Patient) first or last name". Leave any questions that don't apply to your situation blank.
We keep your information confidential.

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Question - Required - Are you a:





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Question - Required - Patient gender:


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Question - Not Required - Generally speaking, what would be the best times for an S2S call from the volunteer?

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(Maximum response 255 chars, approx. 5 rows of text)

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Question - Required - What would the patient like to discuss with the S2S volunteer?
Please make at least 1 selection from the choices below.

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Question - Not Required - If you would like to talk about the bladder removal surgery (radical cystectomy): what urinary diversions are you considering? You may select more than one.

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