Report a Late Diagnosis of a Child with
Cancer or Leukemia
Your Contribution to Early Diagnosis Research and Training
(Please Fax Completed 2 Page Form to 310-454-9592)
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Patient's Name: Parent's Names: |
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Address: |
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Phone: Fax: Email: |
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Patient's Age: |
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Late Diagnosis/Misdiagnosis Information: |
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Date of First Symptoms: Detailed Description of First Symptoms: |
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Date of First Healthcare Practitioner Visit: Tests Performed: |
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Initial Diagnosis (Misdiagnosis): Doctor's Name: |
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Initial Treatment based on Misdiagnosis: Type of Doctor: |
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Doctor's Address, Phone, and Email: |
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Correct Diagnosis Information: |
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Date of Cancer or Leukemia Diagnosis: Type of Doctor: |
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Doctor's Name, Address, Phone, and Email: |
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What test(s) were used to make the proper diagnosis? |
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Was there metastatic disease at the time of diagnosis? |
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Other Important Information: |
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What do you think would have helped expedite a correct diagnosis? |
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How many days from the date that cancer or leukemia was first suspected was a biopsy done? |
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How many days from the date of the biopsy was chemotherapy started? |
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What other suggestions, information, or feedback would you like to offer? Would you like a referral? |
I represent that all of the information provided is true and correct to the best of my knowledge. I hereby grant permission to The Cure Our Children Foundation (hereafter, the Foundation) to use the information as it sees fit without limitation, including for publication in any media as long as my name and contact information are withheld. I agree that name and contact information may be provided to licensed medical professionals or attorneys. I hereby release the Foundation for any claims, whether known or unknown, arising from the Foundation's use of the information. I agree that no representations or warranties have been made by the Foundation regarding any outcome, result, or other representations, and I agree that the Foundation, its affiliates, employees, administrators, directors, officers and agents shall not be liable for, and shall be held harmless for any loss or damage whatsoever to me or my family as a result of the usage of the information. The Foundation is authorized to receive and review any medical records regarding this report. A fax copy of this form may be treated as an original.
Signature (Parent, Guardian, or Patient over 18 years old) Printed Name Date
The Cure Our Children Foundation
http://www.cureourchildren.org