Cancer Studies Contact Form

Requester (non-patient) Information

If you aren't the patient, please answer the questions below and then complete the patient information for the patient. If you are the patient, please skip this section and complete only the patient information section.

Patient Information



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Additional Information

What motivated you to contact the Mayo Clinic? Select all that apply.

Are you taking anti-convulsants or anti-seizure medications?

Do you have a history of heart problems?

Do you have cancer?

Is this a new diagnosis?

Has the cancer spread to the brain?

Have you had chemotherapy?

Have you had hormonal therapy for cancer treatment?

Have you had radiation

Does Mayo Clinic have your permission to communicate with you via email?