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TCGC TOLL FREE: (877) 900-8894 |
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TEXAS CANCER GENETICS CONSORTIUM |
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| Return to 'How To Participate' Page | Printable Web Page Contact Form |
Contact Information
Please print this web page by clicking the 'File' menu in the
upper left-hand corner of your browser and then 'Print' or 'Print Frame'. If the
choice should be grayed out, click on this page and try again. Complete the form
below to indicate interest in enrolling in the Cancer Genetics Network registry, or to find
out more about being involved. When you have printed and completed the form, please mail the
page to us at the address at the bottom of the page. We will use this form to send you
information, or to call you back by phone at a time convenient to conduct a more detailed
enrollment questionnaire about your medical and family history. When we call, we will
try to answer any questions you may have. Thank you.
| Your Name: | _______________________________________________ |
| Your Address: | ___________________________________________________________ |
| City: | ________________________________ |
| State: | _______________ |
| Zip Code: | ________________________________ |
| Daytime Phone Number: | (_______)________________________ |
| Evening Phone Number: | (_______)________________________ |
| Best times to call you: | __________________________________________________________ (Example: M-F, after 5pm. or Thursday mornings at work) |
| E-Mail Address (if any): | ________________________________ |
| Today's Date: | _________/_____/_________ month / day / year |
How did you hear about the TCGC or this website? (please check only one)
| ___ Advertisements (radio or newspaper) | ___ Cancer Information Service | ___ Friend or family | |
| ___ Physician | ___ Health fair | ___ Web search | |
| ___ Genetics counselor | ___ Other research project | ___ Other |
| Please mail
this completed form to: Louise Strong, MD c/o Lynda Bushy M. D. Anderson Cancer Center Dept. 209 1515 Holcombe Blvd. Houston, Texas 77030 |