Provider Resource Submission Form

Thank you for being part of BCAN’s effort to inform bladder cancer patients and caregivers about the resources available to them in community practices in the United States. To help us do so, please fill out the fields in the form below. BCAN will review your information, contact you if we have any questions and add it to our database.

"*" indicates required fields

Physician/Practice Information

Practice Name*

Practice Contact Person (will not be displayed publicly)

Name*

First Name Last Name

Specialty*

Location Details

Address*

Address 1 Address 2 City State Zip Code

Care Provided

Bladder Cancer Diagnoses Treated*

Upper Tract Urothelial Carcinoma (UTUC-low and high grade)

Non-Muscle Invasive Bladder Cancer (includes Ta, T1, CIS tumors)

Muscle Invasive Bladder Cancer (includes T2 tumors)

Locally Advanced (includes T3 tumors)

Metastatic Bladder Cancer (includes T4 tumors)

Treatment Options*

Elements of Excellent Care Provided*

Does your practice offer a support group?

Yes

Contact Information

Phone Number*

Email Address*

Website Link*

Additional Information (Optional)

Languages Spoken

Accessibility Features

Have questions or problems? Please email [email protected]

Provider Resource Submission Form

Physician/Practice Information

Location Details

Care Provided

Contact Information

Additional Information (Optional)

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