Application to Become A Patient Teacher

Contact Information

The following information will allow us to contact you.

Preferred method of communication:


The following information you share will give us an insight into what types of experiences and stories you will bring to the program as a patient teacher.

1. At which hospital/health care centre did you receive the majority of your treatment and care?

St. Michael’s HospitalSunnybrook HospitalPrincess Margaret/University Health NetworkOther-specify below:

5. What types of treatments did you receive? (please select all that apply)

Mastectomy SurgeryLumpectomy SurgeryBreast reconstruction SurgeryColorectal surgeryPlease list any surgeries

ChemotherapyRadiationEndocrine therapy (oral pills)Adjuvant TherapiesOther - specify:

6. Which of the following best describes your gender identity?

FemaleMaleIntersexTransgender - female to maleTransgender - male to femaleDo not knowPrefer not to answerOther - please specify

Preferred pronouns

7. Which of the following best describes your racial or ethnic group identity?

Asian – East (e.g. Chinese, Japanese, Korean)Asian - South (e.g. Indian, Pakistani, Sri Lankan)Asian - South East (e.g. Malaysian, Filipino, Vietnamese)Black - African (e.g. Ghanaian, Kenyan, Somali)Black – Caribbean (e.g. Barbadian, Jamaican)Black – North American (e.g. Canadian, American)First NationsIndian - Caribbean (e.g. Guyanese with origins in India)Indigenous/Aboriginal – not included elsewhereInuitLatin American (e.g. Argentinean, Chilean, Salvadoran)MétisMiddle Eastern (e.g. Egyptian, Iranian, Lebanese)White – European (e.g. English, Italian, Portuguese, Russian)White – North American (e.g. Canadian, American)Do not knowPrefer not to answer

10. How did you hear about becoming a patient teacher? (please select all that apply)

Patient as Teacher program websiteHospital Patient and Family Advisory CommitteeCIBC Breast Cancer CentreCommunity organizationFrom a surgeon/physician/health care professionalFrom friends/familyFrom a patient teacherOther – specify:

By filling out this form I consent to being contacted with regards to becoming a patient teacher

Please indicate whether you consent to your online application form to be part of the Patients as Teachers study. Please see detailed informed consent form.

Yes, I consentNo, I do not consent