BMT Navigation Request

Our BMT Patient Navigators provide support, reliable and easy to understand information and resources from diagnosis through recovery for transplant patients, caregivers and families. Please complete this form if you would like a BMT Patient Navigator to contact you.

1. Contact/ general information:

Today's date:*

First name:*

Last name:*

Which best describes you:*

Select or enter value

If you selected 'other' for which best describes you, please specify:

Phone number:*

E-mail address:*

Contact preference:*

Select or enter value

How can we help you?

2. Consent to receive text messages from Be The Match

By selecting “I Agree” below, I authorize Be The Match Patient Support Center to contact me by SMS text message as a way to communicate with me. Be The Match will send me text messages through the Be The Match Patient Support Center outreach texting program to help me, my child or my loved one. I understand that standard messaging and data rates may apply to messages sent by the Be The Match Patient Support Center to my cell phone. I understand that text messages are not a substitute for professional or medical attention. I know that I am under no obligation to authorize Be The Match Patient Support Center to send me text messages as part of this program. I may opt-out of receiving these communications from Be The Match Patient Support Center at any time by texting 'STOP' to (888) 999-6743.

Online Consent: Please select one option below

Select

3. Demographic Questions

We ask the last few questions so we can design programs and resources that are tailored to your needs and preferences. If you do not wish to answer these question please select 'prefer not to answer.'

Your ethnicity:*

Hispanic or Latino

Not Hispanic or Latino

Prefer not to answer

Your race:

Select all that apply:

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Not listed

Prefer not to answer

If you selected 'not listed' for your race, please specify:

If you selected 'not listed' for your highest level of education, please specify:

Send me a copy of my responses

Privacy Notice|Report Abuse