www.advocacyconnector.com Open in urlscan Pro
75.13.79.58  Public Scan

Form analysis
1 forms found in the DOM

Name: acForm —

<form id="acForm" name="acForm">
  <input type="hidden" name="gretoken" id="gretoken" value="">
  <div class="row">
    <div class="col-12 col-sm-6">
      <label class="form-label" for="diagnosisSelect">Select a Cancer Type</label>
      <span id="diagnosisError" class="form-error text-danger"></span>
      <select id="diagnosisSelect" class="form-select" name="diagnosisGUID">
        <option value="">- Select an option -</option>
        <option value="AC3E1FF5-502D-476F-8A1B-9D14D0E3DA38">Bladder Cancer</option>
        <option value="A991577A-936F-4419-A9BB-0BD32883B571">Brain Cancer</option>
        <option value="DC59819B-7D61-4A7F-BE75-337F673BF37A">Breast (Metastatic)</option>
        <option value="62FBEADA-FED3-4E63-9AC7-A712C2B56AB9">Breast Cancer</option>
        <option value="7379B9BA-8C7E-48D5-A946-46C4A358800A">Colorectal Cancer</option>
        <option value="73C3FD74-975D-43FB-B4C5-0CD6875D5C25">General (non-specific cancer groups)</option>
        <option value="01D3CA7D-25CF-4BAE-B03F-192A6AA91541">Leukemia</option>
        <option value="AD61AD4F-BE6A-4701-A855-353EF5751489">Leukemia (Childhood)</option>
        <option value="C8A32B77-55F5-41B8-8C04-175AFA827D3B">Lung Cancer</option>
        <option value="43EF2197-EB42-403B-B1E8-6B15602CA921">Lymphoma</option>
        <option value="3EF0FBB8-DDDC-4A3D-B238-A4874620848F">Melanoma</option>
        <option value="1B617D75-6F80-4B2D-8D2B-A2457DF913D4">Myelofibrosis</option>
        <option value="069C60F0-7266-45EC-B4CE-70BAFAC5A561">Myeloma</option>
        <option value="ED225770-0619-4D9A-B247-42EA71D345D7">Ovarian Cancer</option>
        <option value="135F4022-B876-4B3B-B8AC-E53858D1A95D">Pancreatic Cancer</option>
        <option value="3A3F764E-36E8-46C8-A074-D36EA36C7A1D">Prostate Cancer</option>
        <option value="0B088C8F-9455-436E-AA12-C56CCD218E53">Sarcoma</option>
        <option value="1AB88289-68C6-4093-AA36-242333189A0B">Waldenstrom's</option>
      </select>
    </div>
  </div>
  <div class="row">
    <div class="col-12 col-sm-6">
      <label class="form-label" for="zipInput">Zip/Postal Code</label>
      <span id="zipError" class="form-error text-danger"></span>
      <input id="zipInput" type="text" class="form-control" name="Zip" maxlength="5" value="">
    </div>
    <div class="col-12 col-sm-6">
      <label class="form-label" for="distanceSelect">Distance From You</label>
      <select id="distanceSelect" class="form-select" name="Distance">
        <option value="5">Within 5 Miles</option>
        <option value="10">Within 10 Miles</option>
        <option value="25" selected="">Within 25 Miles</option>
        <option value="50">Within 50 Miles</option>
      </select>
    </div>
  </div>
  <label class="form-label mt-3">Select Services (select all that apply)</label>
  <span id="servicesError" class="form-error text-danger"></span>
  <div class="checkbox-parent service">
    <div>
      <div class="check-group"><input type="checkbox" id="Advocacy Help Lines" class="check" name="serviceGUID" value="3F8D404B-AEC5-43BE-81DF-41A2FE765694"><label for="Advocacy Help Lines" class="form-label check">Advocacy Help Lines</label></div>
      <div class="check-group"><input type="checkbox" id="Alternative &amp; Complimentary Therapies" class="check" name="serviceGUID" value="4049DFC5-C5AD-45F0-A051-E1ED8038AD86"><label for="Alternative &amp; Complimentary Therapies"
          class="form-label check">Alternative &amp; Complimentary Therapies</label></div>
      <div class="check-group">
        <label class="checkbox-expandable form-label check" data-bs-toggle="collapse" data-bs-target="#childCategories_3" aria-expanded="false" role="button" aria-controls="#childCategories_3" tabindex="0">
          <i class="fas fa-plus-square text-secondary"></i> Camps/Retreats </label>
        <div id="childCategories_3" class="collapse checkbox-container">
          <div class="sub-checkbox-parent">
            <div class="check-group"><input type="checkbox" id="Adults" class="check" name="serviceGUID" value="C0D37035-1C70-4E70-8A8E-735B74B5A7F9"><label for="Adults" class="form-label check">Adults</label></div>
            <div class="check-group"><input type="checkbox" id="Child" class="check" name="serviceGUID" value="CBDD3A44-7821-4D39-A4FA-E62E362B3866"><label for="Child" class="form-label check">Child</label></div>
            <div class="check-group"><input type="checkbox" id="Family" class="check" name="serviceGUID" value="1FADAD2E-206A-451C-8247-8CE211F56F6B"><label for="Family" class="form-label check">Family</label></div>
          </div>
        </div>
      </div>
      <div class="check-group"><input type="checkbox" id="Cancer Research" class="check" name="serviceGUID" value="E05BCDE6-1A27-4C84-8E9C-3461DA76FEDF"><label for="Cancer Research" class="form-label check">Cancer Research</label></div>
      <div class="check-group"><input type="checkbox" id="Caregiver Support" class="check" name="serviceGUID" value="72B79219-4131-4FBA-8C98-4AA333918079"><label for="Caregiver Support" class="form-label check">Caregiver Support</label></div>
      <div class="check-group"><input type="checkbox" id="Clinical Trials Information" class="check" name="serviceGUID" value="644A8B0B-E175-43AB-96B0-C9AEACB5439B"><label for="Clinical Trials Information" class="form-label check">Clinical Trials
          Information</label></div>
      <div class="check-group"><input type="checkbox" id="Counseling" class="check" name="serviceGUID" value="B3BE764A-7277-4227-B4BE-FDA51026ACF5"><label for="Counseling" class="form-label check">Counseling</label></div>
      <div class="check-group"><input type="checkbox" id="End of Life Care" class="check" name="serviceGUID" value="135650FA-7640-4499-A2C6-DD6086B01F6D"><label for="End of Life Care" class="form-label check">End of Life Care</label></div>
      <div class="check-group">
        <label class="checkbox-expandable form-label check" data-bs-toggle="collapse" data-bs-target="#childCategories_11" aria-expanded="false" role="button" aria-controls="#childCategories_11" tabindex="0">
          <i class="fas fa-plus-square text-secondary"></i> Exercise </label>
        <div id="childCategories_11" class="collapse checkbox-container">
          <div class="sub-checkbox-parent">
            <div class="check-group"><input type="checkbox" id="Classes" class="check" name="serviceGUID" value="7AC5A7DF-F932-4622-A95B-0EE550450338"><label for="Classes" class="form-label check">Classes</label></div>
            <div class="check-group"><input type="checkbox" id="Information" class="check" name="serviceGUID" value="B486DEFC-3B8A-4B27-AC6A-2A45ADDA37A9"><label for="Information" class="form-label check">Information</label></div>
            <div class="check-group"><input type="checkbox" id="Videos" class="check" name="serviceGUID" value="58040593-1D97-42C0-A644-8D42854F34EE"><label for="Videos" class="form-label check">Videos</label></div>
          </div>
        </div>
      </div>
      <div class="check-group">
        <label class="checkbox-expandable form-label check" data-bs-toggle="collapse" data-bs-target="#childCategories_14" aria-expanded="false" role="button" aria-controls="#childCategories_14" tabindex="0">
          <i class="fas fa-plus-square text-secondary"></i> Financial Assistance </label>
        <div id="childCategories_14" class="collapse checkbox-container">
          <div class="sub-checkbox-parent">
            <div class="check-group"><input type="checkbox" id="Child care" class="check" name="serviceGUID" value="55646340-4FA3-4202-A4D3-1E91A7AD8E0C"><label for="Child care" class="form-label check">Child care</label></div>
            <div class="check-group"><input type="checkbox" id="Co-pay Assistance" class="check" name="serviceGUID" value="50820271-DF24-4846-B97C-943EFFBB7811"><label for="Co-pay Assistance" class="form-label check">Co-pay Assistance</label></div>
            <div class="check-group"><input type="checkbox" id="House cleaning" class="check" name="serviceGUID" value="801C3086-8D45-45EA-A9CC-D70AE8C411DC"><label for="House cleaning" class="form-label check">House cleaning</label></div>
            <div class="check-group"><input type="checkbox" id="Medical bills" class="check" name="serviceGUID" value="CD790B7A-61F7-44A4-9CCB-DEA7FB7BCBD9"><label for="Medical bills" class="form-label check">Medical bills</label></div>
            <div class="check-group"><input type="checkbox" id="Monetary Travel Assistance" class="check" name="serviceGUID" value="99862223-E272-495C-B020-67B304DF14E7"><label for="Monetary Travel Assistance" class="form-label check">Monetary Travel
                Assistance</label></div>
            <div class="check-group"><input type="checkbox" id="Other" class="check" name="serviceGUID" value="126E32F3-82B3-4E65-AC40-19C7FCFE4FB7"><label for="Other" class="form-label check">Other</label></div>
            <div class="check-group"><input type="checkbox" id="Prescription Assistance" class="check" name="serviceGUID" value="3AAF08B5-01A6-4136-BD29-9155C5C4A1E0"><label for="Prescription Assistance" class="form-label check">Prescription
                Assistance</label></div>
            <div class="check-group"><input type="checkbox" id="Rent/living expenses/food" class="check" name="serviceGUID" value="01F0CAE7-98EE-484D-9C63-54A31A4E6B02"><label for="Rent/living expenses/food" class="form-label check">Rent/living
                expenses/food</label></div>
          </div>
        </div>
      </div>
      <div class="check-group">
        <label class="checkbox-expandable form-label check" data-bs-toggle="collapse" data-bs-target="#childCategories_22" aria-expanded="false" role="button" aria-controls="#childCategories_22" tabindex="0">
          <i class="fas fa-plus-square text-secondary"></i> Housing </label>
        <div id="childCategories_22" class="collapse checkbox-container">
          <div class="sub-checkbox-parent">
            <div class="check-group"><input type="checkbox" id="Affordability" class="check" name="serviceGUID" value="A4070B56-CD4D-4133-A32C-011622883E2C"><label for="Affordability" class="form-label check">Affordability</label></div>
            <div class="check-group"><input type="checkbox" id="Shelters" class="check" name="serviceGUID" value="56966E66-8640-4CC9-865A-940F60D9BE2C"><label for="Shelters" class="form-label check">Shelters</label></div>
            <div class="check-group"><input type="checkbox" id="Short-term stay" class="check" name="serviceGUID" value="A94D5179-4724-4D7F-93FB-6E75D61F7C07"><label for="Short-term stay" class="form-label check">Short-term stay</label></div>
          </div>
        </div>
      </div>
      <div class="check-group"><input type="checkbox" id="Legal &amp; Insurance Assistance" class="check" name="serviceGUID" value="D5C3A05E-88EE-4FF7-B8F9-67AF5BD875F5"><label for="Legal &amp; Insurance Assistance" class="form-label check">Legal
          &amp; Insurance Assistance</label></div>
    </div>
    <div>
      <div class="check-group">
        <label class="checkbox-expandable form-label check" data-bs-toggle="collapse" data-bs-target="#childCategories_26" aria-expanded="false" role="button" aria-controls="#childCategories_26" tabindex="0">
          <i class="fas fa-plus-square text-secondary"></i> Materials in Other Languages </label>
        <div id="childCategories_26" class="collapse checkbox-container">
          <div class="sub-checkbox-parent">
            <div class="check-group"><input type="checkbox" id="Chinese" class="check" name="serviceGUID" value="799A0F1C-4165-413F-8E6B-26EAE97993B4"><label for="Chinese" class="form-label check">Chinese</label></div>
            <div class="check-group"><input type="checkbox" id="French" class="check" name="serviceGUID" value="9BF2685E-6414-439C-894A-03EB16A14DCA"><label for="French" class="form-label check">French</label></div>
            <div class="check-group"><input type="checkbox" id="Mandarin" class="check" name="serviceGUID" value="84D08AC7-4538-4126-A901-DDA4A3FFF6F7"><label for="Mandarin" class="form-label check">Mandarin</label></div>
            <div class="check-group"><input type="checkbox" id="Russian" class="check" name="serviceGUID" value="8037A59D-20C5-4BE2-BF09-E8B6393E5938"><label for="Russian" class="form-label check">Russian</label></div>
            <div class="check-group"><input type="checkbox" id="Spanish" class="check" name="serviceGUID" value="54FFD8F1-285F-487A-89D9-9048714B88BA"><label for="Spanish" class="form-label check">Spanish</label></div>
          </div>
        </div>
      </div>
      <div class="check-group"><input type="checkbox" id="Men's Health Issues" class="check" name="serviceGUID" value="C4AF5A63-9F5B-4496-881C-5B5A16B824CD"><label for="Men's Health Issues" class="form-label check">Men's Health Issues</label></div>
      <div class="check-group">
        <label class="checkbox-expandable form-label check" data-bs-toggle="collapse" data-bs-target="#childCategories_32" aria-expanded="false" role="button" aria-controls="#childCategories_32" tabindex="0">
          <i class="fas fa-plus-square text-secondary"></i> Nutrition </label>
        <div id="childCategories_32" class="collapse checkbox-container">
          <div class="sub-checkbox-parent">
            <div class="check-group"><input type="checkbox" id="Articles/Podcasts/Webinars" class="check" name="serviceGUID" value="DD6B57A5-EDBC-4CB1-9DEB-6A0CA6D82104"><label for="Articles/Podcasts/Webinars"
                class="form-label check">Articles/Podcasts/Webinars</label></div>
            <div class="check-group"><input type="checkbox" id="Food Assistance" class="check" name="serviceGUID" value="40734080-64D0-4F2D-BFEC-EFEC4A6AA7B4"><label for="Food Assistance" class="form-label check">Food Assistance</label></div>
            <div class="check-group"><input type="checkbox" id="Food Pantry" class="check" name="serviceGUID" value="C5EDCAD1-9BA1-421F-91CD-93FBD96982E2"><label for="Food Pantry" class="form-label check">Food Pantry</label></div>
            <div class="check-group"><input type="checkbox" id="Recipes" class="check" name="serviceGUID" value="5E578EA4-EF64-4A03-BAB2-7224904AD30F"><label for="Recipes" class="form-label check">Recipes</label></div>
          </div>
        </div>
      </div>
      <div class="check-group"><input type="checkbox" id="Pain Management &amp; Palliative Care" class="check" name="serviceGUID" value="0F2F3904-04D5-492C-9B69-5040ED3F2E2F"><label for="Pain Management &amp; Palliative Care"
          class="form-label check">Pain Management &amp; Palliative Care</label></div>
      <div class="check-group"><input type="checkbox" id="Patient Education" class="check" name="serviceGUID" value="95280262-48CB-4DAD-BD20-5AC967D47F94"><label for="Patient Education" class="form-label check">Patient Education</label></div>
      <div class="check-group"><input type="checkbox" id="Patient Support" class="check" name="serviceGUID" value="36663506-0847-4AD6-BBEE-013A74E8FB36"><label for="Patient Support" class="form-label check">Patient Support</label></div>
      <div class="check-group"><input type="checkbox" id="Screening &amp; Early Detection" class="check" name="serviceGUID" value="48593B4E-E89A-40B9-AFCD-9356068CACB6"><label for="Screening &amp; Early Detection" class="form-label check">Screening
          &amp; Early Detection</label></div>
      <div class="check-group"><input type="checkbox" id="Spiritual Support" class="check" name="serviceGUID" value="D5D44801-F365-4F50-8752-5C0DD5F0F04A"><label for="Spiritual Support" class="form-label check">Spiritual Support</label></div>
      <div class="check-group"><input type="checkbox" id="Survivorship" class="check" name="serviceGUID" value="64E2F376-DABB-4849-8849-4DFD56B29C50"><label for="Survivorship" class="form-label check">Survivorship</label></div>
      <div class="check-group">
        <label class="checkbox-expandable form-label check" data-bs-toggle="collapse" data-bs-target="#childCategories_42" aria-expanded="false" role="button" aria-controls="#childCategories_42" tabindex="0">
          <i class="fas fa-plus-square text-secondary"></i> Travel Services </label>
        <div id="childCategories_42" class="collapse checkbox-container">
          <div class="sub-checkbox-parent">
            <div class="check-group"><input type="checkbox" id="Air travel" class="check" name="serviceGUID" value="2423FF14-7BC9-4F93-9335-0232820DD617"><label for="Air travel" class="form-label check">Air travel</label></div>
            <div class="check-group"><input type="checkbox" id="Car rides" class="check" name="serviceGUID" value="E6CF72FD-E505-4D7F-943C-587EAB9D6B21"><label for="Car rides" class="form-label check">Car rides</label></div>
            <div class="check-group"><input type="checkbox" id="Travel grants" class="check" name="serviceGUID" value="89E7DE1A-1AB5-41B2-91B8-418C0EB8E4AF"><label for="Travel grants" class="form-label check">Travel grants</label></div>
          </div>
        </div>
      </div>
      <div class="check-group">
        <label class="checkbox-expandable form-label check" data-bs-toggle="collapse" data-bs-target="#childCategories_45" aria-expanded="false" role="button" aria-controls="#childCategories_45" tabindex="0">
          <i class="fas fa-plus-square text-secondary"></i> Veterans Services </label>
        <div id="childCategories_45" class="collapse checkbox-container">
          <div class="sub-checkbox-parent">
            <div class="check-group"><input type="checkbox" id="Emotional Support" class="check" name="serviceGUID" value="5B1B68CD-878A-4AAB-8E30-F75F3CBA31A4"><label for="Emotional Support" class="form-label check">Emotional Support</label></div>
            <div class="check-group"><input type="checkbox" id="Family/Caregiver Support" class="check" name="serviceGUID" value="247CEB74-0DFB-4F45-B7E7-E2AF14035FF1"><label for="Family/Caregiver Support" class="form-label check">Family/Caregiver
                Support</label></div>
            <div class="check-group"><input type="checkbox" id="Financial Assistance" class="check" name="serviceGUID" value="3BEC4502-CC1F-427F-8F5E-0B5B84B172AE"><label for="Financial Assistance" class="form-label check">Financial
                Assistance</label></div>
          </div>
        </div>
      </div>
      <div class="check-group"><input type="checkbox" id="Women's Health" class="check" name="serviceGUID" value="ABBB8732-4552-4F8E-806C-835374DDC4E1"><label for="Women's Health" class="form-label check">Women's Health</label></div>
      <div class="check-group"><input type="checkbox" id="Young Adult Cancer Support" class="check" name="serviceGUID" value="78562B73-76D6-4CE8-9354-AD994FE841EA"><label for="Young Adult Cancer Support" class="form-label check">Young Adult Cancer
          Support</label></div>
    </div>
  </div>
  <button class="btn btn-primary">Submit</button>
</form>

Text Content

FIND ADVOCACY GROUPS NEAR YOU

Complete the search criteria to find an advocacy group.

Select a Cancer Type - Select an option - Bladder Cancer Brain Cancer Breast
(Metastatic) Breast Cancer Colorectal Cancer General (non-specific cancer
groups) Leukemia Leukemia (Childhood) Lung Cancer Lymphoma Melanoma
Myelofibrosis Myeloma Ovarian Cancer Pancreatic Cancer Prostate Cancer Sarcoma
Waldenstrom's
Zip/Postal Code
Distance From You Within 5 Miles Within 10 Miles Within 25 Miles Within 50 Miles
Select Services (select all that apply)
Advocacy Help Lines
Alternative & Complimentary Therapies
Camps/Retreats
Adults
Child
Family
Cancer Research
Caregiver Support
Clinical Trials Information
Counseling
End of Life Care
Exercise
Classes
Information
Videos
Financial Assistance
Child care
Co-pay Assistance
House cleaning
Medical bills
Monetary Travel Assistance
Other
Prescription Assistance
Rent/living expenses/food
Housing
Affordability
Shelters
Short-term stay
Legal & Insurance Assistance
Materials in Other Languages
Chinese
French
Mandarin
Russian
Spanish
Men's Health Issues
Nutrition
Articles/Podcasts/Webinars
Food Assistance
Food Pantry
Recipes
Pain Management & Palliative Care
Patient Education
Patient Support
Screening & Early Detection
Spiritual Support
Survivorship
Travel Services
Air travel
Car rides
Travel grants
Veterans Services
Emotional Support
Family/Caregiver Support
Financial Assistance
Women's Health
Young Adult Cancer Support
Submit

Disclaimer:

Patient Resource LLC provides the information contained in the Advocacy
Connector as a public service supported by Johnson & Johnson, Inc. Neither
Patient Resource LLC nor Johnson & Johnson, Inc., are responsible for the
content or Privacy Policy of any third-party websites. We encourage you to read
the Privacy Policy of every website you visit. All information has been verified
for accuracy, but neither Johnson & Johnson, Inc., nor Patient Resource LLC can
guarantee that all information remains up-to-date.



© 2024 Patient Resource LLC

Privacy Policy|Disclaimer|Contact Us