MCJ Self-Referred Intake Survey

The MyCancerJourney service includes the guidance and assistance of a Patient Advocate -- board certified and specialized in cancer care. They will help you understand your diagnosis and your treatment options, answer questions, advocate for your needs, and ultimately help ensure you get the best care for you -- tailored to your specific situation and goals.

MyCancerJourney is offered at no cost through several providers and health plans. For those not covered, a self-pay option is available.

Once you complete the form below, your Patient Advocate will contact you within one (1) business day.

For more information, visit https://www.mycancerjourney.com.

First Name*

Last Name*

Date of Birth*

Best Contact Phone Number*

Best Contact Email Address*

Phone (recommended)EmailText

MorningAfternoonEveningOther

Type of cancer you have been diagnosed with*

Self-referral -- I found MyCancerJourney on my own (web, ad, etc)Surest memberMy primary care physician referred me

YesNo

My Products*

MyCancerJourney - 1 user license

When you complete your purchase, you will be contacted by a patient advocate within one (1) business day. We will ask you a few questions to make sure we can assist you and request credit card information, which we'll use for payment. Then, our navigator will assist you in gathering data about your diagnosis from your physician(s), discuss your diagnosis and treatment options with you thoroughly, and securely deliver to you the report you can take to your doctor.

$2,200.00

Total

$0.00

Credit Card

Get Started with MyCancerJourney

Credit Card