Register for CHESS

In order to participate in CHESS, it is necessary that you read and accept the
Terms and Conditions

CLICK HERE

The information you provide using the form below will be sent to the CHESS Program Coordinator at Hartford Hospital who will verify your eligibility. You will be contacted by phone or email within two business days to verify your access code name and password so you can use CHESS anonymously. If you do not own a computer, one will be provided to you. 
 
If you prefer not to submit the requested information using this form, please contact the CHESS project coordinator during regular business hours for assistance.

NOTE: The Coping with Prostate Cancer module is currently undergoing maintenance and is unavailable. During this time we are not taking registrations for this program. We hope to have the module available soon.

11.14.13


* = Required

* I am interested in:
Coping With Breast Cancer module
* Terms & Conditions: Yes, I have read the terms and conditions
* Registrant:
I am a Hartford Hospital Patient
I am NOT a Hartford Hospital Patient, but I am interested in CHESS
I am a Caregiver/Supporter
* Diagnosed with:
Breast cancer
Advanced metastatic breast cancer
* Diagnosis determined:
Within the last two months
More than two months ago
  My Doctor's Name is:
  I learned about CHESS from...
Hartford Hospital
Hartford Hospital Web Site
Doctor's Office
Friend/Relative
Hartford Hospital publication
Other publication
Other (please specify):
     
  I would describe my comfort-
  level using the Internet as...
 

Very Comfortable
Comfortable
Neutral
Uncomfortable
Very Uncomfortable  


Contact Information:
* First Name:
* Last Name:
* Gender: Male Female
* Date of Birth:
* E-Mail Address:
* Phone Number:
  Mailing Address: Street: 

City, State, Zip: ,   


Create a User Account:
* Code Name: (must be at least 6 letters/numbers, no spaces)
* Password: (must be at least 6 letters/numbers, no spaces,
and different than the Code Name)

 
* Security Code:

Enter code shown above:
 

Submit my registration:




Once your information is received, the CHESS Program Coordinator will enter it into the CHESS system and will contact you via phone or email within two business days to verify your registration.  You will then be able to login to the CHESS website using this link.