All information provided will be kept strictly confidential and is for Virtual Tumor GIST Board only. We are committed to protecting the privacy of those participants. Any data or information that we share in any way is always cleansed of identifying information in order to protect confidentiality.
This form is for the treating physician to fill out. Please fill out this form to the best of your knowledge and circle the appropriate options.
You may mail or fax the completed form to our office at:
NIH-LRG Virtual GIST Tumor Board
c/o The Life Raft Group
155 US Highway 46, Ste. 202
Wayne, NJ 07470
Fax to: (973) 837-9095
E-mail to: firstname.lastname@example.org
*If you have any immediate needs or questions please call us at
973-837-9092 ext. 114 (9a.m.-5p.m. EST)