Newly Diagnosed/ Newly Connected Welcome Survey

Questions marked with a * are required
Welcome to the Cholangiocarcinoma Foundation. 

We are so glad you found us. We appreciate the opportunity to support you or a loved one as you navigate the cholangiocarcinoma diagnosis journey. Please complete this short survey so we can understand how we may best help you. This survey will take approximately ten minutes to complete. This survey also serves as an order form for eligible households to receive a free Newly Diagnosed Care Kit.
Are you a cholangiocarcinoma patient or caregiver? 
Please provide the patient's contact information: 
Which of the following best represents the patient's ethnicity?
Which of the following best represents the patient's race?
Which of the following best represents the patient's gender?
What is the patient's marital status?
Does the patient have any children?
What is the patient's highest level of education?
What type of health insurance does the patient have?
What is the patient's total annual household income before taxes? (Please include money earned by the patient, spouse/partner, and any other adult in the household. Please give us your best estimate if you’re not sure.)
How did the patient hear about the Cholangiocarcinoma Foundation?
Would the patient like to receive text messages from the Cholangiocarcinoma Foundation?
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