Send Love Today

Send Love Today provides emotional support and encouragement to brain tumor patients and their families throughout their difficult journey. We lighten their burden with a smile by sending homemade cards and small gifts filled with personalized messages of love, support and friendship.

Patient Questionnaire:

In order to send cards and gifts that are most appropriate, please provide the following patient information, which will be kept strictly confidential.

Send Love Today’s Patient Privacy Statement:

Send Love Today respects the privacy of all of our patients, and we will not give your personal information to anyone without your prior consent.  By submitting this completed questionnaire to Send Love Today, you thereby give us your consent to provide only our volunteers with the information provided on this form, in order that they may send you personalized cards.  At no time will they be given any medical information about you.  If you prefer not to have your personal information given to our volunteers, we offer you the following options.
Please select your preference:

It is okay to give the information on this questionnaire to Send Love Today’s volunteers so that they may send cards directly to me.

I would rather receive only 1-4 cards per month, directly from Send Love Today founders rather than from volunteers.

I will obtain a post office box and use that address rather than my home address.  In this case, Send Love Today’s volunteers will be given only my first name and first initial of my last name and my post office box information.  [Note: Your post office may even donate the post office box if you explain the circumstances.]
I would like you to call me to discuss other alternatives.
Name
Address
City
State
Zip Code
Telephone
Best time to call
eMail Address
Birth Date
Gender
Male Female
Family Contact and/or Primary Care Giver:
Name
(We will contact this person on a monthly basis for health updates on the patient.)
Family Contact Telephone
Family Contact eMail
Best time to reach you
The Patient's Favorites:
Favorite Color
Favorite Snack
Favorite Music
Favorite TV Shows/Movies
Hobbies
Other
Do you celebrate any religion?
Yes No
If so, which one?
How many cards per week would you like to receive? Please select below:
1 card 2 cards 3 cards More if possible
How did you find out about Send Love Today?
You may withdraw from Send Love Today’s program or change any of the information given in this questionnaire by calling (800) 716-7703 or by sending an email to linda@sendlovetoday.org
Please feel free to tell us anything else that you would like us to know about you:

Send Love Today’s website includes a monthly Profile in Courage.  If you would like to be high-lighted one month, please check “yes” below and we will contact you for more information.
Yes No, thank you.

Consent:
by clicking here, you, the patient or the parent of a minor child, give Send Love Today your consent to give their volunteers only my personal information as listed as my preference above on this questionnaire.
Your Name
Relationship to patient
by clicking here, you give Send Love Today your consent to give their volunteers the personal information of the patient as listed as his/her preference above on this questionnaire. The patient is aware of Send Love Today's program.
Please indicate your agreement to the terms above:
Yes, I agree to the terms above.
No, I do not agree to the terms above.
I have additional questions.
THANK YOU for taking the time to complete this questionnaire!

If you have any questions, comments or concerns, please email me at linda@sendlovetoday.org
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