Comfort Care and Compassion Program Request

The Comfort Care and Compassion Program

A diagnosis of cervical cancer is devastating and can seem so lonely. The Comfort Care & Compassion Program Powered by Cervivor provides those with a current or prior diagnosis of cervical cancer with that little extra something to help carry them through the day. Please complete this request form to send a gift of Comfort Care & Compassion to yourself or someone who has or is dealing with cervical cancer. Please allow 1-2 weeks for processing and shipping. Thank you for your patience and understanding! If you have any questions, please reach out to [email protected]!
Please select one.
Name
Name
First
Last
Address
Address
City
State/Province
Zip/Postal
Country
I would like to send/receive a:
What is your relationship to care package recipient?
Please check the box below if you wish your gift to remain anonymous.
If you selected a Greeting Card, please let us know which option you would prefer. If this is not the option you selected please skip this question.
If applicable, please indicate language preference below.
If you selected the tote bag care package, is the recipient newly diagnosed or receiving active treatment for metastatic or recurrent cervical cancer?
Where are they/you currently in their/your cervical cancer journey?
If you chose the Milestone option, Please select the number of years from the dropdown menu. (Please Note: Milestone pins are sent out for 1, 5, 10, 15, and 20 year benchmarks. If the requested milestone is not one of the mentioned benchmarks, an acknowledgement will still be sent to the recipient).
Name
Name
First
Last
Address
Address
City
State/Province
Zip/Postal
Country
In our efforts in providing services with diversity, equity, and inclusion as a top priority, we ask if you would kindly share the recipient/your ethnicity.
If applicable, please indicate language preference below.