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Cancer Studies Contact Form

If you do not read/speak English, please call 855-776-0015 (toll-free) for interpreter services.

Has the patient received care at Mayo Clinic before?
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Requester (non-patient) Information

If you aren't the patient, please answer the questions below and then complete the patient information for the patient. If you are the patient, please skip this section and complete only the patient information section.

(optional)'Requester name:' is a required field. ('Requester name:' es un campo obligatorio.)'Requester name:' is a required field. ('Requester name:' es un campo obligatorio.)
(optional)'Relationship to patient:' is a required field. ('Relationship to patient:' es un campo obligatorio.)'Relationship to patient:' is a required field. ('Relationship to patient:' es un campo obligatorio.)
(optional)Please ensure the email address is valid and follows the standard format — for example, johndoe@isp.com. (Por favor, asegura que el correo electrónico sea válido y que siga el formato estándar — por ejemplo, johndoe@isp.com. )
Patient Information
Enter legal first name (Completar con el primer nombre legal)Enter legal first name (Completar con el primer nombre legal)
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(optional)Middle name: must have at least 0 and no more than 256 characters.The value of the Middle name: field is not valid.
Enter last name (Completar con el apellido)Enter last name (Completar con el apellido)
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Gender:
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*
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Identifying your race and ethnicity assures that everyone gets appropriate access to the health care they need. The information you report is voluntary and confidential.If other, please specify: must have at least 0 and no more than 256 characters.The value of the If other, please specify: field is not valid.
(if applicable)Maiden name: must have at least 0 and no more than 256 characters.The value of the Maiden name: field is not valid.
(if applicable)Spouse name: must have at least 0 and no more than 256 characters.The value of the Spouse name: field is not valid.
(if applicable)Previous married name: must have at least 0 and no more than 256 characters.The value of the Previous married name: field is not valid.
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Street: must have at least 0 and no more than 256 characters.The value of the Street: field is not valid.
Address: must have at least 0 and no more than 512 characters.The value of the Address: field is not valid.
City: must have at least 0 and no more than 256 characters.The value of the City: field is not valid.
State Other: must have at least 0 and no more than 256 characters.The value of the State Other: field is not valid.
Zip: must have at least 0 and no more than 256 characters.The value of the Zip: field is not valid.
Postal code: must have at least 0 and no more than 256 characters.The value of the Postal code: field is not valid.
Phone: must have at least 0 and no more than 256 characters.The value of the Phone: field is not valid.
(optional)Alternative phone: must have at least 0 and no more than 256 characters.The value of the Alternative phone: field is not valid.
(optional)Please ensure the email address is valid and follows the standard format — for example, johndoe@isp.com. (Por favor, asegura que el correo electrónico sea válido y que siga el formato estándar — por ejemplo, johndoe@isp.com.)
(if applicable)Mayo Clinic patient number: must have at least 0 and no more than 256 characters.The value of the Mayo Clinic patient number: field is not valid.
Additional Information
What motivated you to contact the Mayo Clinic? Select all that apply.
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Are you taking anti-convulsants or anti-seizure medications?
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Do you have a history of heart problems?
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Do you have cancer?
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Cancer Type: must have at least 0 and no more than 512 characters.The value of the Cancer Type: field is not valid.
Is this a new diagnosis?
Has the cancer spread to the brain?
Have you had chemotherapy?
If yes, please enter the names of the chemotherapy drugs. must have at least 0 and no more than 512 characters.The value of the If yes, please enter the names of the chemotherapy drugs. field is not valid.
Have you had hormonal therapy for cancer treatment?
Have you had radiation?
If no, is there a particular study about which you'd like more information? must have at least 0 and no more than 512 characters.The value of the If no, is there a particular study about which you'd like more information? field is not valid.
Does Mayo Clinic have your permission to communicate with you via email?
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(optional. limit 1,000 characters)Additional comments: must have at least 0 and no more than 1000 characters.The value of the Additional comments: field is not valid.

Mayo Clinic Number

Your Mayo Clinic number is a 7, 8 or 9-digit number we assign to you as a new patient prior to your first visit. You can find it near the top of a range of documents, including pre-visit questionnaires, clinical notes, care summaries, and correspondence.

If you do have Mayo paperwork handy, it's often quickest simply to look for it there. Scroll down to see some examples of how the number shows up:

In correspondence:

Image of Form: Authorization for Mayo Clinic to Disclose Protected Health Information

In pre-appointment questionnaires

Image of Form: Authorization for Mayo Clinic to Disclose Protected Health Information

In medical documents:

Image of Form: Authorization for Mayo Clinic to Disclose Protected Health Information

In dismissal summaries:

Image of Form: Authorization for Mayo Clinic to Disclose Protected Health Information

In several other kinds of documents:

Image of Form: Authorization for Mayo Clinic to Disclose Protected Health Information

Important: After submission, please do not leave this form until you see the confirmation message.

Mayo Clinic Number

Your Mayo Clinic number is a 7, 8 or 9-digit number we assign to you as a new patient prior to your first visit. You can find it near the top of a range of documents, including pre-visit questionnaires, clinical notes, care summaries, and correspondence.

If you do have Mayo paperwork handy, it's often quickest simply to look for it there. Scroll down to see some examples of how the number shows up:

In correspondence:

Image of Form: Authorization for Mayo Clinic to Disclose Protected Health Information

In pre-appointment questionnaires

Image of Form: Authorization for Mayo Clinic to Disclose Protected Health Information

In medical documents:

Image of Form: Authorization for Mayo Clinic to Disclose Protected Health Information

In dismissal summaries:

Image of Form: Authorization for Mayo Clinic to Disclose Protected Health Information

In several other kinds of documents:

Image of Form: Authorization for Mayo Clinic to Disclose Protected Health Information
.

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