Treatment Center Registration

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Please fill out the following form with as much accuracy as possible.* If you prefer to fill out a paper form and fax it back to the NBTF office, you can download a copy here. Please fax it back to 415.834.9980, attn: Patient Services - Treatment Center Database


*Please note: although you are being asked for your e-mail, this information will not be posted on the website. This is solely for contact purposes with NBTF and will not be shared with any other third parties.


Name of Treatment Center:
Clinical Coordinator/Contact Name:

Neurosurgeons and/or Neuro-oncologists at this center (please include first name, last name and credentials):

Doctor’s name Neurosurgeon Neuro-oncologist
Address Line 1:
Address Line 2:
Address Line 3:
Address Line 4:
City:
State:
Zip:
Email:
Phone:
Fax:
Website:

  • Approximately how many brain tumor surgeries are performed at your facility annually (Please note that "surgery" does NOT include stereotactic radiosurgery, such as Gamma Knife, Cyberknife, Novalis, etc)?

    Fewer than 25 25-50 51-100
    101-150 151-200 201-300
    More than 300

  • What type of intraoperative technologies does your treatment center use? Check all that apply.

    Intraoperative MRI
    Tesla =
    		Intraoperative CT
    Brain mapping
    		 Awake craniotomy
    Image-guided surgery
    		 None

  • Approximately how many brain tumor patients receive radiation therapy from your facilty per year (Please note that "surgery" does NOT include stereotactic radiosurgery, such as Gamma Knife, Cyberknife, Novalis, etc)?

    Fewer than 25 25-50 51-100
    101-150 151-200 201-300
    More than 300

  • What type of stereotactic radiosurgery technologies does your treatment center use? Check all that apply.

    Gamma Knife Synergy
    CyberKnife Trilogy
    LINAC Brainlab M3
    X-Knife Nomos/Corvus
    Novalis Other
    Other=
    None

  • Approximately how many brain tumor patients receive stereotactic radiosurgery from your facility per year?

    Fewer than 25 25-50 51-100
    101-150 151-200 201-300
    More than 300

  • Is there a brain tumor board system in place at your facility?

    Yes No

    If Yes, what disciplines attend tumor board meetings? Check all that apply.

    Neurosurgeon(s) Research staff
    Neuro-oncologist(s) Neuro-pathologist(s)
    Radiation oncologist(s) Neuro-radiologist(s)
    Endocrinologist(s) Social worker
    Neuro-psychologist Clinical nurses

  • Do you collaborate with cooperative research group protocols (i.e. RTOG, COG, NABTC, NABTT)?

    Yes No

    If Yes, which ones?



  • Is there an existing brain tumor support group at your treatment center?

    Yes No
    If Yes, please list the location, facilitator and contact information to the best of your knowledge:

  • Please list any additional information or comments about your center here:


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  • Receive Information on Upcoming Events, Brain Tumor News and Treatment Updates.