Pediatric Brain Tumor Foundation - Georgia Chapter
Working to eliminate the challenges
of childhood brain tumors
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Family Profile Form

 

The Pediatric Brain Tumor Foundation invites you to complete our family profile form to join our family database. We’ll send you informative emails, newsletters and notices about social activities available for your child and your family. There’s no charge for any of our services or activities, and we will not give or sell your address to anyone.

Patient First Name
Patient Last Name
Nickname
Gender
Date of Birth
Race
Ethnicity
Primary Language
Treatment Facility
Primary Physician
Diagnosis
Date of Diagnosis
Date of Death (if applicable)
Name of Parents or Guardian
Street Address
City
State
Zip Code
County
Home Phone
Work Phone
Cell Phone
Email Address 1
Email Address 2
Please list any websites or Facebook pages you use to update family and friends on your child's health
Sibling Name
Sibling DOB
Sibling gender
Sibling 2 Name
Sibling 2 DOB
Sibling 2 gender
Anything special you would like to tell us about your child? Ex: hobbies, likes/dislikes, etc.
How did you hear about us
I hereby authorize the staff of the Pediatric Brain Tumor Foundation to obtain information from and/or provide information to the medical staff at the treatment facility listed above Yes, I agree
Signature of Parent or Guardian
By entering your name, you electronically authorize as specified in the above document.
Relationship to Patient
     
NOTE: The release of information may be revoked at any time by the persons signed above. All revocations must be made in writing and signed by persons above.