Cancer Survey Registration

Pillar Patient Advocates LLC is a private patient advocacy firm specializing in assisting patients navigate the healthcare system. At times, market research firms request our assistance in finding patients to share their journeys through surveys, interviews, focus groups or other types of market research. Patients are paid an honorarium in appreciation for their time. If you or a loved one has been diagnosed with cancer, please provide input to the questions below. All information is strictly confidential. By submitting this form, you are giving permission for Pillar Patient Advocates to contact you when a market research study opportunity is available for the disease or illness indicated. You will also be given the option to opt-out of receiving such opportunities. Thank you, in advance, for completing the questionnaire.

1.Are you a cancer patient or caregiver to a cancer patient?(Required.)

Cancer Patient

Caregiver to a cancer patient

Neither

3.Email Address(Required.)

4.Confirm Email Address(Required.)

5.What is your first name?(Required.)

6.What is your last name?(Required.)

7.City(Required.)

8.In what state do you reside?(Required.)

9.In what country do you live?(Required.)

10.Phone Number

11.In what year were you born? (enter 4-digit birth year; for example, 1976)(Required.)

12.I am interested in market research for other diseases affecting me or my family. Please contact me for the following diseases or illnesses.

Disease/Illness 1:

Disease/Illness 2:

Disease/Illness 3:

Disease/Illness 4: