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Patient Form

Family / Patient Information

If your child has been diagnosed with cancer, LCH, HLH, brain tumor, or aplastic anemia, and you would like more information from CURE, please complete this form. (Para completar el formulario en español, haga clic aquí.)

"*" indicates required fields

Patient's First Name*

First

Patient's Last Name*

Last

Date of Birth*

MM slash DD slash YYYY

Age*

Gender*

Patient's Ethnicity*

Asian/Pacific Islander

Black/African American

Hispanic/Latino

Native American

White/Caucasian

Other

Diagnosis Type*

Date of Diagnosis*

MM slash DD slash YYYY

Treatment Status*

On treatment

Off treatment

Relapsed/Progression

Date of relapse/progression

MM slash DD slash YYYY

Parent/Guardian First Name*

First

Parent/Guardian Last Name*

Last

Relation to Patient*

Cell Phone*

Email Address*

Street Address*

City*

State*

State

Zip Code*

Would you like to add contact information for child's other parent/guardian?

Yes

No

Parent/Guardian Name

Relation to Patient

Cell Phone

Email Address

Address (leave blank if same as parent 1)

Street Address City State / Province / Region ZIP / Postal Code

Siblings of Patient

Name

M/F

Birthdate

Is your child currently receiving treatment?*

Yes

No

Has your child completed treatment?

Yes

No

Date completed treatment

MM slash DD slash YYYY

Has your child had their first Survivorship Clinic appointment?

Yes

No

When is your child expected to begin treatment?

Treating Hospital*

Children's Healthcare of Atlanta

Dwaine & Cynthia Willett Children's Hospital Of Savannah

Nemours Children's Specialty Care

Other

Did you receive a CURE Tote?

Yes

No (Please request one from your social worker)

Social Media or Caring Bridge

We'd like to follow your child's journey

Please let us know how you learned about this patient information form?*

CURE Tote

Social Worker or other hospital staff member

CURE Staff Member

CURE Website

CURE QR Code

Other

CAPTCHA

Email

This field is for validation purposes and should be left unchanged.

Legal
Privacy Policy

CURE Childhood Cancer
200 Ashford Center North, Suite 250
Atlanta, GA 30338

CURE Childhood Cancer is a non-profit 501(c)(3) organization, IRS identification number 58-1244138.

© 2024 CURE Childhood Cancer. | ALL RIGHTS RESERVED | LEGAL

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About CURE
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- Host a Fundraiser
Ways To Give
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