To become a member of the "Floridabob", the information shown below is required. To obtain a copy of the "Membership Form", send an e-mail, with your name and e-mail address to me at:
bobfurlong@floridabob.org
or
refurlong@bellsouth.net
and I will send you a copy of the form for your completion. Upon receipt of your completed form, I will send you conformation of your acceptance into the "Floridabob".
Last Name:
First Name:
Spouse:
Address:
City:
State:
Zip Code:
Phone:
Email:
Type of Cancer Being Treated:
Treatment Start Date:
PSA at Treatment Start:
PSA Three Months After End of Treatment:
Gleason Score:
Receiving “Balloon” or “Saline Solution”:
Have You Been Treated for Prostate Cancer Before, Yes or No:
If "Yes" What Form of Treatment Did You Receive and When:
Did your Urologist refer you for "Proton Therapy Treatment" or are you a self referral Patient:
Treatment Information for all Members
Treatment Information for Prostate Cancer Patients Only
Contact Details for all Members
Share Information Yes or No:
NO MEDICAL ADVICE:
Material appearing here represents opinions offered by non-medically-trained laypersons. Comments shown here should NEVER be interpreted as specific medical advice and must be used only as background information when consulting with a qualified medical professional.
Can We Share Your Information with Non-Members
That Are Evaluating Proton Therapy Treatment?
Floridabob Membership Sign-up Form Information
floridabob@bellsouth.net
-
Note: If Treatment Start Date Has Not Been Determined,
Enter “TBD” for To Be Determined
Treatment End Date:
Age at Start of Treatment:
