We appreciate your interest in the
Epidermoid Brain Tumor Registry and the role it will play in
further studying this type of tumor. Please fill in the following
information and submit it. We may contact you for further
information if necessary. This registry will enable us to follow
epidermoid brain tumor patients over many years, hopefully
shedding new light on what treatments and procedures work best.
All information will remain confidential. Thank you for your
participation.
First Name:
Last Name:
Address 1:
Address 2:
City:
State:
Zip Code:
Country:
Phone Number:
Email Address:
Time
preferred
to be called:
Member of family
with Epidermoid tumor:
Their date of
birth:
Gender:
Male
Female
When
tumor was first diagnosed (month/year):
Date
of surgery/surgeries:
You've
been diagnosed but not had surgery (Watch and Wait)
Yes:
No:
Any
other family members with epidermoids, brain or elsewhere?
Yes:
No:
If
yes to above question, who and what location:
Are
there any deficits?
Yes:
No:
Would
you be willing to participate in a long term study of this
type tumor?
Yes:
No:
Where
did you hear about this site: (e.g. web page, Doctor,
friend)
Comments:
Please
check your answers carefully. If there is a mistake, simply
scroll up to make any needed changes
