Teal Travels - Ovarcoming Cancer, Celebrating Life

We asked: when and if you need to travel reasonably long distance for treatment, what are the items you’d need most and what are your major concerns?

You gave us guidance, shared your concerns, and helped us design Teal Travels – our travel assistance program for Ovarcomers and families.

Our Teal Travels program is available only in Houston, TX at this time in our home city. As we expand our services, we will update accordingly.

What are the eligibility requirements?

Patient in active treatment for ovarian cancer – 12 years old and over
Residence at least 50 miles from the cancer treatment center
Referral from a doctor, social worker, or nurse navigator
Completed application form submitted 35-60 days ahead of treatment date
Not have received Teal Travels assistance in the past 7.5 months

What does Teal Travels offer?

King room or a Double Queen room at an exclusive to Ovarcome rate
One complimentary night of stay provided by Ovarcome
Welcome dinner & beverage for our Ovarcomer – healthy salad or sandwich
Shuttle service to and from treatment within 5 miles of hotel
Welcome Bag filled with essentials to keep you embraced in Ovarcoming
Gift card to help just a little with gas, tolls, parking

Lodging Options:

Hotel stay with Four Points by Sheraton Houston Energy Corridor
Longer term home stay with Teal Casa King

Option 1: Four Points by Sheraton Houston Energy Corridor

Booking requirement:

A valid credit card is required at the time of booking.
Guest will be responsible for hotel incidentals upon arrival. Incidentals may vary.

Option 2: Teal Casa King Long Term Lodging

10 minimum nights at a special rate
Refundable Deposit fee as determined by property
Cleaning fees as determined by property
Welcome Basket filled with essentials to help you Ovarcome
Gift card to help just a little with gas, tolls, parking

At Ovarcome, we are inspired by the simple philosophy of support, love, and celebration of life.
I hereby confirm: I reside and receive treatment in the United States (citizenship not required), I understand an application is not a guarantee of receiving the accommodation or associated services and is subject to availability. I will need to provide all supporting documents needed for the application to request travel assistanceI am applying on behalf of my patient, and I understand and accept the requirements described above Teal Travels Application: Steps & Guidelines Apply in 3 steps: Review the application formFill out the application form and have it verified by your healthcare teamSubmit along with supporting documents to us for review PATIENT IDENTIFICATION AS WE GET TO KNOW YOU – REQUIRED STEPS: A recent picture is required for identification purposes (driver’s license picture not accepted)
Date: *
First Name: *
Last Name: *
Address: *
Phone number: *
Email Address: *
Date of birth: *
Name of parent or guardian * If patient is a minor (under 18):
Ethnicity: *	CaucasianAfrican AmericanLatinoAsianOther
Anticipated date of travel for treatment *:
Physician name *:
Nurse/Social Worker name *:
Physician/Nurse/Social Worker Address *:
Hospital Name * :
Hospital Address * :
Please upload your recent picture *
MEDICAL INFORMATION * THIS SECTION MUST BE COMPLETED BY YOUR ONCOLOGY NURSE, DOCTOR, OR SOCIAL WORKER ONLY *
Is patient in active treatment? *	YesNo
If not in active treatment, indicate frequency of follow-up: *	Bi-AnnualOther
Please indicate type of treatment(s) received in past twelve months (check all that apply) * ChemotherapyRadiationSurgeryPalliative care
RELEASE CONSENT FORM
Release Permission: I In signing this Consent, I understand and acknowledge that: (add check marks for all): I will not receive any remuneration for the use of my name, media coverage, or quote.I am over 18 years of age and otherwise legally competent to sign this Release.I have read this Release in its entirety and understood it prior to executing it.
Date: *
Email Address: *
All information is strictly confidential and is for Ovarcome official use only I understand an application is not a guarantee of receiving Teal Travels GrantI attest all information provided is accurate and up to date

Via OvarCare Counseling we are pleased to offer: Up to 6 sessions of support for up to 6 months Meetings by phone in any location in the U.S. Supportive services to OvarCare grant recipients Information, resources, referrals as needed and requested Our OvarCare counseling sessions are designed to provide support through the journey of Ovarcoming Ovarian Cancer and are not deemed to be psychotherapy services. Our members are ready to provide compassionate and meaningful support via active listening, providing gentle guidance in navigating the often-challenging course of diagnosis, treatment and survivorship, and in providing effective tools and resources to Ovarcome. Please complete the fields below to register for our counseling program: We are here to Ovarcome with you. Welcome to our safe and friendly space. This is a complimentary service as part of our OvarCare Program and is currently available in English only.
Information
Name: *
Date of birth: *
Email Address: *
Address: *
Do you consent to receiving text messages from your OvarCare Support Services?: *	YesNo
Share with us the best way to reach you: *	EmailPhoneText MessageAll of the above
Primary Phone Type: *	MobileLandline
Please indicate your time zone: *	Eastern TimeCentral TimeMountain TimePacific Time Hawaii-Aleutian Time
What do you wish to accomplish from these support sessions? Please share your personal goal: *
Please carefully review the acknowledgements below: 1. OvarCare support services are designed to provide emotional and informational support and is not intended to provide any medical guidance. It is also not intended to provide psychotherapy, crisis management critical mental health issues2. You will be offered up to 6 counseling sessions for up to 6 months as part of this program. You will be contacted via the information you provide to us. Ovarcome is not responsible to maintain privacy of information if provided outside of the channels indicated on the form3. You agree to indemnify, defend, release and hold harmless Ovarcome, their employees, officers, directors, agents, successors and assigns, against all liabilities, claims, causes of action, damages, judgments, costs or expenses, including attorney's fees, caused by, resulting from or which arise in connection with your participation in OvarCare Support Services Program
Acknowledgement of My Consent BY CHECKING THIS CONSENT, I CERTIFY THAT: I have carefully read and consent to the terms and conditions stated herein.
Name: *
Date: *

What are the eligibility requirements?

What does Teal Travels offer?

Lodging Options:

Option 1: Four Points by Sheraton Houston Energy Corridor

Option 2: Teal Casa King Long Term Lodging

Submit Your Details & Reserve

PATIENT IDENTIFICATION AS WE GET TO KNOW YOU – REQUIRED STEPS:

MEDICAL INFORMATION

*** THIS SECTION MUST BE COMPLETED BY YOUR ONCOLOGY NURSE, DOCTOR, OR SOCIAL WORKER ONLY ***

RELEASE CONSENT FORM

RESERVATION

Our Haven of Hope: Teal Travels Program is supported by

* THIS SECTION MUST BE COMPLETED BY YOUR ONCOLOGY NURSE, DOCTOR, OR SOCIAL WORKER ONLY *