Login to the Patient Portal
Schedule and Appointment
Thank you very much for participating in Hartford Hospital’s Cancer Survivorship Program.

As part of our survivorship services, we invite you to access your records through our secure, online patient portal. This is a website that both you and your care providers can use to manage your survivorship care. This site allows you to access your treatment summary and follow-up schedule, review the educational material created for you and complete questionnaires assigned to you.

In order to access the patient portal you must have already had a visit with the Survivorship Nurse Practitioner and received your Treatment Summary, Care Plan, and Patient Portal login. If you have already had your visit, we encourage you to log in to the portal to access and view all of your survivorship information.

If you have not yet made a survivorship appointment and would like to, please call (860) 545-1209 or click here to schedule your cancer survivorship appointment.

Schedule an Appointment with the Survivorship Nurse Practitioner:

* = Required field

* Registrant: I am a Hartford Hospital Patient
I am NOT a Hartford Hospital Patient, but I am interested
      in the Survivorship Program
(Please Note – Survivorship appointments are only available to Hartford Hospital Patients at this time)
* First Name:
* Last Name:
* Gender: Male Female
* Date of Birth:
* E-Mail Address:
* Phone Number:

  Best Time to contact:
* Mailing Address: Street:
City:  
State: Zip: 
* Acknowledgement of Billing: I understand that my health insurance will be billed for this
     visit, and I am responsible for any copays or other associated
     charges not covered under my insurance. 
* What is your cancer
  diagnosis?
Breast cancer
Prostate cancer
Colorectal Cancer
Other (please specify): 
* Date of Surgery (Enter "N/A" if not applicable)
* Last Day of Chemotherapy  (Enter "N/A" if not applicable)
* Last Day of Radiation  (Enter "N/A" if not applicable)
* Medical Oncologist’s Name:  (Enter "N/A" if not applicable) 
  Hospital they are from
  (if not Hartford Hospital)
* Surgeon’s Name:  (Enter "N/A" if not applicable) 
  Hospital they are from
  (if not Hartford Hospital)
* Radiation Oncologist’s Name: (Enter "N/A" if not applicable)
  Hospital they are from
  (if not Hartford Hospital)
* Primary Care Physician’s Name:
  Other Provider’s Name:
  (i.e. OB/GYN, etc.)
  I learned about Hartford
  Hospital’s Cancer
  Survivorship Program from...
Hartford Hospital
     (please specify):
      
Hartford Hospital Web Site
Doctor's Office
     (please specify):
    
Friend/Relative
Hartford Hospital publication
     (please specify):
Other publication
     (please specify):

Internet Search
     (please specify):
Other
     (please specify):
   
* Preferred appointment
  location:
Hartford  Avon
  Please specify three dates
  you would like for your
  survivorship visit:
  (Appointments are available
  Monday – Friday)
Choice 1:
Choice 2:
Choice 3:
I would prefer a phone call to set up my appointment
  Please specify the best time
  for your appointment
Morning (9:00 AM – 11:00 AM)
Afternoon (12:30 PM – 4:00 PM)
Other (please specify):     
  Add me to the Cancer
  Support Group Mailing List:
Add me to your Email list:     Yes  No
Add me to your mailing list:  Yes  No


* Enter Code Shown Above: