Patient Support Services
Visitors' Programs Online Form

*Patient Name(First) *(Last) Company name (if applicable) *Address Line 1: Address Line 2: *City: *State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY Other *Zip: Business Phone Number (if okay to call at work) Date of Birth Gender Male Female If hospital in-patient, name of hospital Room Number Date of Discharge In what specific treatment areas would you ideally like support: Surgery Chemotherapy Radiation therapy Ostomy Reconstructive surgery Prosthesis Side effects of treatment: Other: What characteristics would you prefer in a visitor: Same Sex Same Age Marital Status Children Similar occupation/retired Active in specific sport Other preferences Type of visit requested: Home visit Hospital Visit Telephone calls only Comments:     Name of referring person Date I, hereby authorize the Cancer Center of Santa Barbara to release the above information to a volunteer Visitor assigned to me.  I further understand that the volunteer Visitor may discuss information regarding my situation or condition with the Patient Care Coordinators at the Cancer Center of Santa Barbara.