Information Request Form – Radiation Oncology


Tackle Cancer with Radiation Therapy


IMPORTANT: If you are experiencing a serious medical emergency, call 911.

If you or someone you know has been diagnosed with cancer, complete this form and we will contact you about new radiation therapy options available. 

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Name:  

Phone:   (format 1234567 no spaces or dashes)

E-mail:

Message: (Optional)
 

Please contact me with information about this type of cancer:

Please contact me with more information about CyberKnife® at Sylvester.

Please contact me about clinical trials.

I would like to schedule a consultation with a Sylvester oncologist who specializes in my type of cancer to discuss my next steps.

Information collected from this website will be used by Sylvester/UMHC, part of UHealth — University of Miami Health System, in order to process your request.

This is a secure site and your information will be kept confidential.

In order to confirm that you have read and agree to the above, please type  AGREE  in the box:

 

Disclaimer:
The content published by the Sylvester website is for informational purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Sylvester and the University of Miami will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising there from.