Northeastern Oklahoma Cancer Network
Please fill out the application below; a member of our team will be in touch within in three business days. By clicking submit below you certify that the information provided is true.
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
I currently live or work in Rogers or Mayes County, Oklahoma.
*
Yes
No
I am currently receiving chemotherapy, immunotherapy, or radiation treatment.
*
Yes
No
Name of medical oncologist/radiation oncologist:
*
Are you currently receiving cancer treatment at Northeastern Oklahoma Cancer Institute in Claremore?
Yes
No
Attach a note from your oncologist/radiation oncologist stating currently receiving chemotherapy, immunotherapy, or radiation treatment, and your cancer diagnosis:
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At any point during your cancer treatment, have you considered skipping a meal due to the cost of food?
*
Yes
No
At any point during your cancer treatment, have you considered skipping treatment due to the cost of fuel?
*
Yes
No
What type of assistance are you requesting today?
*
QT Gas Card
Walmart Gift Card
Other
Any other information you feel we need to know?
How did you hear about us?
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