Make a referral

To refer an individual living with cancer to Gilda’s Club, please fill out the form below. Once their information has been received, one of our team members will reach out to them. Information provided will remain confidential; however, names will be added to our patient services mailing list. For any questions, please call the Clubhouse at 312-464-9900.

Gilda’s Club Professional Referral Form

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Individual being referred

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Professional making the referral

Patient confidentiality agreement

To ensure patient privacy while disclosing protected health information, my electronic signature below serves as confirmation the patient has agreed to my releasing this information to Gilda’s Club Chicago.
Official Signature
Please type in your name and today's date. You agree that this will be used as your official signature.