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Dempsey Center›Registration Forms›Client Information Update Form

Client Information Update

We hope you are continuing to find Dempsy Center’s services helpful as you navigate the impact of cancer—whether for yourself or in support of a loved one.
Providing us with the most recent infomation about your cancer impact helps us to insure uninterrupted access to serveices and better meet your individual needs.

Thank you for taking the time to update your information!

Name:(Required)
Email:(Required)
Please confirm your preferred email.
Has your phone number changed in the past year?
Is this your cell?(Required)
OK to leave a voice or text message?(Required)
What is your preferred method of messaging:(Required)
Are you interested in continuing to access Dempsey Center services?(Required)
Has there been any change to your physical address in the past year?(Required)
Address:
Has your Emergency Contact changed in the past year?(Required)
Emergency Contact:(Required)
I most often use Dempsey services:(Required)
Information regarding Employment and Health Insurance is gathered solely for Dempsey Center grant application and funding purposes. Employment status and/or insurance coverage have no impact on one’s ability to be a client at the Dempsey Center. We will never contact your employer or insurer on your behalf, nor will we submit insurance claims for clients. All personal information provided will be kept confidential.
Current Employment Status:
Health Insurance Status:
What is your cancer impact?(Required)
Please check all that apply.
Please provide information about your or your loved one’s cancer diagnosis
Have you or your loved one received a new cancer diagnosis, had a reoccurance, or metastisis in the past year?(Required)
month/year
Current Treatment Status(Required)
Treatment Types Received in the past year:(Required)
Select all that apply

Please review our Privacy Policy by clicking the link below. It will open in a new window. You will need to return back to this window to check the box that you have read and understand it and then click Submit.

Dempsey Center Code of Conduct

Click here to review our Client Code of Conduct.
I have reviewed and agree to the Dempsey Center Client Code of Conduct.(Required)
MM slash DD slash YYYY

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Find Us

Lewiston
29 Lowell Street
Lewiston, ME 04240

1-877-336-7287

Hours:
Mon: 8:00 AM - 5:00 PM
Tues: 10:00 AM - 7:00 PM
Wed: VIRTUAL ONLY (8:00 AM - 5:00 PM)
Thurs: 8:00 AM - 5:00 PM
Fri: VIRTUAL ONLY (8:00 AM - 12:00 PM)
Sat-Sun: Closed

Rock Row - Westbrook
11 Rock Row, Suite 410
Westbrook, ME 04092

1-877-336-7287

Hours:
Mon: 8:00 AM - 5:00 PM
Tues: 10:00 AM - 5:00 PM
Wed: 8:00 AM - 5:00 PM
Thurs: 8:00 AM - 7:00 PM
Fri: VIRTUAL ONLY (8:00 AM - 12:00 PM)
Sat-Sun: Closed

Find Us

Lewiston
29 Lowell Street
Lewiston, ME 04240

1-877-336-7287

Hours:
Mon: 8:00 AM - 5:00 PM
Tues: 10:00 AM - 7:00 PM
Wed: VIRTUAL ONLY (8:00 AM - 5:00 PM)
Thurs: 8:00 AM - 5:00 PM
Fri: VIRTUAL ONLY (8:00 AM - 12:00 PM)
Sat-Sun: Closed

Rock Row - Westbrook
11 Rock Row, Suite 410
Westbrook, ME 04092

1-877-336-7287

Hours:
Mon: 8:00 AM - 5:00 PM
Tues: 10:00 AM - 5:00 PM
Wed: 8:00 AM - 5:00 PM
Thurs: 8:00 AM - 7:00 PM
Fri: VIRTUAL ONLY (8:00 AM - 12:00 PM)
Sat-Sun: Closed

Donations

Donations may be mailed to:
Dempsey Center
PO Box 277
Auburn, ME 04212
Checks should be made out to the Dempsey Center, please do not mail cash.
EIN Number: 82-1547129

Presented in part by

Donations

Donations may be mailed to:
Dempsey Center
PO Box 277
Auburn, ME 04212
Checks should be made out to the Dempsey Center, please do not mail cash.
EIN Number: 82-1547129

Presented in part by

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