SCAGO Portal

SCAGO Intake & Consent Form

The Sickle Cell Awareness Group of Ontario (SCAGO) is Ontario's largest patient support and advocacy organization. By completing this form, you are providing your information to SCAGO. We store all data securely and will never share your personal information with third parties without your consent.

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Your progress is saved locally and will resume automatically on return.

About SCAGO & Consent to Participate

I confirm that I am 18 years of age or older, OR I am a parent/guardian completing this form on behalf of someone under 18*

Basic Information

Title*

Mrs

Other

First name*

Last name*

Email Address*

Phone Number (Cell)*

Street Address*

City*

Province*

Postal Code*

Your Connection to Sickle Cell Disease

Please select all that apply*

I have sickle cell disease

My child has sickle cell disease

I am a caregiver or family member

I am a healthcare provider

Other

If you selected "Other" above, please describe

Individual 1 - Name

Individual 1 - Date of Birth

Individual 2 - Name

Individual 2 - Date of Birth

Individual 3 - Name

Individual 3 - Date of Birth

Care Information

Which hospital(s) do you/your child primarily receive care from for SCD?*

Stay Connected

May we contact you about SCAGO services, programs, or events?*

Yes

Would you like to join SCAGO's mailing list for updates, newsletters, and advocacy news?*

Yes

Would you like to join our WhatsApp or face-to-face support groups?*

Yes

Do you consent to a SCAGO staff member or Patient Well-Being Coordinator advocating on your behalf when requested?*

Yes

Consent and Confirmation

Full Name (Digital Signature)*

Type your signature here

Use your mouse, finger, or stylus to draw your signature above