Live W.E.L.L.

By completing the information below, you will receive information about related health information from AstraZeneca. You may also receive ongoing information and support related to your condition, including treatment information.

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livewell-registration

First Name*

Last Name*

Email Address*

Email Address Confirmation*

Would you like to receive materials through mail and/or text communications in the future?

Yes No

Address 1

Address 2

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City

ZIP Code

Cell Phone #

By answering the following questions, you will receive information specific to your cancer journey from Live W.E.L.L.

1. Which best describes you?*

I currently have stage 3 non-small cell lung cancer (NSCLC) that cannot be removed by surgery

I’m caring for someone who has stage 3 NSCLC that cannot be removed by surgery

Neither I nor my loved one has stage 3 NSCLC that cannot be removed by surgery

2. Have you or your loved one received chemoradiation therapy (CRT) for your lung cancer?*

Yes, currently treating/planning to treat

Yes, completed treatment

No, and not planning

I’m not sure what my treatment plan will be

3. When is it planned for you or your loved one to complete CRT?*

Within 2 weeks

Within 4 weeks

Within 6 weeks or more

1A. Please select which best describes your type of cancer:*

I currently have stage 1 or 2 non-small cell lung cancer (NSCLC)

I currently have stage 3 NSCLC that has been removed by surgery

I currently have stage 4 NSCLC

I currently have stage 4 NSCLC that tested epidermal growth factor receptor positive (EGFR+)

My loved one or I have a different type of lung cancer

None of the above