| NWCGN Project Line 800-616-8347 |
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Northwest Cancer Genetics Network |
Contact Information- Printable Web Page Contact Form:
Please print this web page and complete the brief contact form
below to indicate interest in enrolling in the registry or to find out more
about being involved. When you have printed and completed it, 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 answer any questions you may have. After completing the
phone questionnaire you be enrolled in the registry.
| Your Name: | ______________________________________________________________ |
| Your Address: |
______________________________________________________________ ______________________________________________________________ |
| State: (must be AK, ID, MT, OR, or WA) | ________ |
| Your Zip Code: | ________________________________ |
| Daytime Phone Number: | (_______)________________________ |
| Evening Phone Number: | (_______)________________________ |
|
Best times to call you:
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______________________________________________________________ Example: M-F, after 5pm. (*See below for our calling out times). |
| E-Mail Address (if any): | ________________________________ |
| Today's Date: | ____/_____/__00 |
How did you hear about the NWCGN or this website? (please check one only)
| ___ advertisements (radio or newspaper) | ___ Cancer Information Service | ___ friend or family | ___ genetics counselor | ___ other research project |
| ___ physician | ___ health fair | ___ web search | ___ other. |
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Please mail this completed form to: The NW Cancer Genetics Network Thank you. |
We are available to call you back at the following times (PST):
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