contact-physicians

Anmeldeformular Einweiser EN

PRACTICE INFORMATION

Name of practice*

Address of practice*

Email address of practice*

Telephone number of practice*

PATIENT INFORMATION

First name*

Last name*

Date of birth*

Telephone*

Why do you want to register your patient?*

Presentation to our outpatient clinic

Second opinion

Presentation to one of our tumor boards

Assessment for potential inclusion in a trial

Are you contacting us about*

A tumor diagnosis for which the patient is not currently being treated?

A disease for which the patient has already received treatment?

A suspected tumor disease?

Date of diagnosis

Type of cancer/suspected tumor disease*

The patient’s state of health permits them to attend the Dresden center independently.

Does the patient have statutory or private health insurance?

statutory

private

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

Previous findings relating to the disease

Please send us your records containing medical findings as a PDF. These include doctors’ letters (in-patient and outpatient), histopathological reports including, where relevant, reference histology, operation reports, any chemotherapy or tumor drug therapy administered, including the name of the drug and the period of administration, recent lab findings, and written findings from medical imaging (preliminary findings and during treatment).

Medical images on CDs

Please send us any CDs by post. Nationales Centrum für Tumorerkrankungen Dresden (NCT/UCC)Portalgebäude Haus 31C, SekretariatFetscherstrasse 74, 01307 Dresden

Please answer the following question to prevent spam.*

Notice

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

Fields marked with a * are required

Contact form for referring physicians

NCT/UCC Dresden
Supporting Institutions

Structural Support