Culinary Care Eligibility Form [Dallas, TX]
Please use this form to see if our program will meet your needs and get connected to the best member of our team to assist you.
Your Full Name
*
First Name
Last Name
Your Email
*
example@example.com
Your Phone
*
Please enter a valid phone number.
What time are you typically in chemo treatment?
*
I/we are usually in treatment from 12 - 12:30 pm CST
I/we are done with treatment before 12 - 12:30 pm CST
I/we arrive for treatment later than 12 - 12:30 pm CST
What hospital is the patient receiving chemotherapy at?
*
UT Southwestern, Outpatient Clinic - Harry Hines Blvd, Dallas, TX
Baylor Scott & White, Sammons Center - Worth St, Dallas, TX
Parkland, Hem/Onc Clinic - Maple Ave, Dallas, TX
Other
If you selected other, please specify the hospital:
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Schedule Your Welcome Call!
Yahoo! We're at your hospital at the right time. Please schedule a welcome call using the calendar below to complete your registration and meet our team.
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You're pre-registration is almost complete!
Please click the "submit" button to officially complete your pre-registration and get connected with our team. Thank you for taking the time to complete this form. Please note that this is not a registration form. We use this form to ensure we can route you to the best answer/next step.
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