Patient Stories

Patient Story Submission Form

Whether you just rang the bell for your last chemotherapy treatment, had a positive experience with your care team or doctor, or want to inspire others with your journey at Clearview, we want to hear from you.

Please fill out the details of your story in the form below. Stories may be featured on Clearview Cancer Institute’s social media accounts, website, or on our blog.

Pick the role that best describes you: *

I am the patient submitting my own story. I am a family member (or caregiver) of the patient and have been given permission to share the patient’s information as filled out in the form below.

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First Name *

Please let us know your name.

Last Name *

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Email *

Please let us know your email address.

Phone Number *

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Clearview Patient Story *

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Clinic Location *

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Patient’s Oncologist/Nurse/Staff member *

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Photo - Video Upload (optional)

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Authorization to Use Information submitted

I grant my permission to Clearview Cancer Institute and/or the Russel Hill Cancer Foundation, to use my story, any photographs and/or video I submitted in the form above in photography, video/audio recordings for presentations, website, reproduction/printed materials, broadcast media, and social media. I further understand these materials may be used in publications, websites, electronic forms, communications, and any type of media.

I waive any right to inspect or have prior approval to photographs, publications, or electronic matter that may be used now or in the future and I waive any right to royalties or other compensation arising from or related to the use of the photographs/information.

I hereby agree to release and hold harmless Clearview Cancer Institute and/or the Russel Hill Cancer Foundation from and against any claims, damages, or liability related to the use of my story, photographs, and/or video for the above items.

Do You Agree to the above Authorization to Use Information? *

Yes

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Please check the box *

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