Contact-Derma

Contact form for referring physicians

Registration form for dermatological tumor board/second medical opinion

Anmeldeformular Einweiser Haut EN

PRACTICE INFORMATION

Name of practice/clinic*

Name of physician*

Address of practice/clinic*

Email address of practice/clinic

Telephone number of practice/clinic*

Fax number of practice/clinic

Your participation at the tumor board*

I will present the patient in the tele-tumor board of the skin cancer center at tuesday 4 pm myself and I will receive a separate invitation via e-mail (e-mail information required, see above). (is preferred)

I will not be able to participate in the tele-tumor board of the skin tumor center. Please send me the tumor board decision via e-mail (transmission is encrypted) or via fax.

Your specialty*

PATIENT INFORMATION

First name*

Last name*

Date of birth*

Telephone*

Type of skin cancer*

Date of diagnosis

Do you wish the therapy at the NCT/UCC?

Yes

No information

Comment

Consent*

Before we can process your enquiry, you must have the patient’s consent for data exchange and presentation to the NCT/UCC tumor board. You hereby confirm that the patient has been informed about the presentation of their case to the NCT/UCC Dresden tumor board and that you have their consent in writing for the presentation of data, findings and images, and for data exchange with University Hospital Dresden.

Medical concern

FINDINGS, IMAGING

Required documents (no presentation without complete documents!)

- Physician's letters / epicrisis with diagnoses and previous therapies (medical/surgical/radiation etc.)
- Histological findings
- Laboratory results
- Imaging (CT, MRT, etc., if possible current and 1-2 older comparative images, with findings)

Possibilities of transmitting findings:

- Fax to: 0351 458-5759
- Mail: Clinic and Polyclinic for Dermatology, PF 38, House 8, UHTC-Secretariat, Fetscherstraße 74, 01307 Dresden, Germany
- File upload (max. 10 MB/file)

Possibilities for image data transfer (CT/MRI/PET-CT):

- UKD-RadioConsil: possible via your radiology if you are an affiliated partner, see list
- external cloud (please send us your link for data download to UHTC@ukdd.de) - CD by mail: Address see above

Please answer the following question to prevent spam.*

Notice

By submitting this form, I agree to the data protection policy.

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Contact form for referring physicians

NCT/UCC Dresden
Supporting Institutions

Structural Support