Your Wellspring Centre:
Wellspring London and Region[change
location ]
This centre will be your home Wellspring centre but you may also attend programs at other
centres.
If you would like to choose a different home centre, you may select
a location .
Date of Birth
Year
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2022
2021
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Month
January
February
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December
Day
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How did you first learn about Wellspring?
Wellspring Member
Wellspring Volunteer or Program
Leader
Word of mouth (e.g.
family, friend, colleague)
Magazine / newspaper / television
Wellspring flyer, pamphlet or
poster
Family doctor
Other health care professional
Website/Internet
Community event
Other organization or community
group
Saw a centre
From treating hospital(s)
Your Home Address
Country
Canada
United States
International / Other
Please select your preferred phone number *
-- Please Select --
Home Number
Mobile Number
Work Number
If you are a cancer patient, please answer the following questions about your
diagnosis.
If you are a caregiver of a cancer patient, please answer the following questions about
the
diagnosis of the person for whom you are caring.
Sometimes, people come to Wellspring who have cancer, and are also caring for a friend or
family member with cancer. If this applies to you, please complete the following
information
based on your diagnosis.
Date of most recent diagnosis:
January
February
March
April
May
June
July
August
September
October
November
December
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
Is this the first diagnosis of cancer?
Yes
No
Primary Hospital receiving treatment at:
Alexandra Hospital
Huron Perth Healthcare Alliance - St. Mary's Memorial Hospital
Huron Perth Healthcare Alliance - Stratford General Hospital
London Health Sciences Centre - University Hospital
London Health Sciences Centre - Victoria Hospital
St. Joseph's Hospital
St. Thomas Elgin General Hospital
Woodstock General Hospital
Other
If applicable
Second Hospital receiving treatment at:
Alexandra Hospital
Huron Perth Healthcare Alliance - St. Mary's Memorial Hospital
Huron Perth Healthcare Alliance - Stratford General Hospital
London Health Sciences Centre - University Hospital
London Health Sciences Centre - Victoria Hospital
St. Joseph's Hospital
St. Thomas Elgin General Hospital
Woodstock General Hospital
Other
Third Hospital receiving treatment at:
Alexandra Hospital
Huron Perth Healthcare Alliance - St. Mary's Memorial Hospital
Huron Perth Healthcare Alliance - Stratford General Hospital
London Health Sciences Centre - University Hospital
London Health Sciences Centre - Victoria Hospital
St. Joseph's Hospital
St. Thomas Elgin General Hospital
Woodstock General Hospital
Other