Patient Referrals

Connect Your Child.

Looking for more information about clinical trials or other opportunities for your child? Please provide some details about the patient in order to connect you with the Beat Childhood Cancer Research Consortium.

Fill out the form below to help expedite your request.

Your Name*
First Last
Email*
Child's Age
Child's Diagnosis
Child's Date of Diagnosis
Month
Day
Year
Child's Treating Physician's Name
First Last
Child's Treating Hospital Name
Child's Current Location/Home
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Child's Treatment History (including chemotherapy, radiation, transplant, etc.)
Current Status of Patient’s Disease (in remission, active disease, extent of disease (ex. localized vs metastatic), etc.)
Do you have a specific question for the BCC Team?
Are you willing to travel if needed?
- Yes
- No