cancer.duke.edu/btc  
The Preston Robert Tisch Brain Tumor Center at Duke

Pediatric Patient Self-Referral

By completing this form, you can start the process of working with us to decide on a plan that is best for the patient.

All messages (phone and online forms) are checked regularly during business hours. We will respond to each message. However, due to the high volume of incoming calls and messages we receive, we ask that you please allow up to three business days for our response.

Our online forms are sent to us via email. Because email does not provide a completely secure and confidential means of communication, please do not use this form if you wish to keep your communication private. Instead, call our main telephone number, 919-684-5301. For more information click the Duke and Your Privacy link at the bottom of this page.

Pediatric Patient Self-Referral
I have read the privacy statement. * Yes
  Information about the pediatric patient\'s parent/guardian
Parent/Guardian First name: *
Parent/Guardian Last name: *
Parent/Guardian Street Address: *
Parent/Guardian City: *
Parent/Guardian State: *
Parent/Guardian Zip: *
Parent/Guardian Country: *
Parent/Guardian Relationship to patient: *
Parent/Guardian Daytime Phone: *
Parent/Guardian Evening Phone: *
Parent/Guardian Email: *
  Information about the patient
Patient First name: *
Patient Last name: *
Patient Date of birth (MM/DD/YYYY):
Patient Gender: Male Female
Patient Diagnosis Information:
Specify Other Diagnosis:
Patient Diagnosis Date (MM/DD/YYYY):
Is the patient currently under treatment? Yes No
If yes, specify current treatment:
Patient Prior Treatments (check all that apply): Surgery Radiation Chemotherapy Gliadel Wafer Stereotactic Surgery Other
Date of Patient Surgery (MM/DD/YYYY):
Date Patient Radiation Treatment Ended (MM/DD/YYYY):
Specify Other Prior Treatments:
If you would like to leave a further message, please type it here:
Reason for referral: * Second Opinion Treatment Options Clinical Trial Other
Specify Other:
 
* Required