Firstname
Lastname
E-mail
Phone
Address
Country
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Azerbaijan
Australia
Bahamas
Bahrain
Bangladesh
Barbados
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Chad
Chile
Colombia
Comoros
Congo
The Cook Islands
Costa Rica
Cuba
Cyprus
Denmark
Central African Republic
Democratic Republic of the Congo
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Ivory Coast
Eritrea
Estonia
eSwatini
Ethiopia
Fiji
Phillipines
Finland
United Arab Emirates
France
Gabon
Gambia
Georgia
Ghana
Grenada
Greece
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Netherlands
Honduras
Belarus
India
Indonesia
Iraq
Iran
Ireland
Iceland
Israel
Italy
Jamaica
Japan
Jordan
Cape Verde
Kazakhstan
Kenya
China
Kyrgyzstan
Kiribati
Kosovo
Croatia
Kuwait
Laos
Lesotho
Latvia
Lebanon
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Morocco
The Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Mozambique
Myanmar (Burma)
Namibia
Nauru
Nepal
New Zealand
Nicaragua
Niger
Nigeria
Niue
North Korea
Northern Macedonia
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Solomon Islands
Samoa
San Marino
Saudi Arabia
Switzerland
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Somalia
Spain
Sri Lanka
United Kingdom
Sudan
Suriname
Sweden
South Africa
South Korea
South Sudan
Syria
São Tomé and Príncipe
Tajikistan
Taiwan
Tanzania
Thailand
Czech Republic
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Tuvalu
Turkey
Germany
Uganda
Ukraine
Hungary
Uruguay
USA
United kingdom
Uzbekistan
Vanuatu
Vatican City State
Venezuela
Western Sahara
Vietnam
Yemen
Zambia
Zimbabwe
Equatorial Guinea
Austria
East Timor
Date of birth
Disease interest: Cancer (Click all that applies)
Breast cancer Bladder cancer Blood cancer (incl. Leukemia) Brain cancer (incl. brain tumor) Colorectal cancer (anal cancer) Ear cancer (incl. ear canal) Eye cancer (incl. retinoblastoma, malignant melanoma) Glands (incl. thyroid, multiple endocrine neoplasia (MEN)) Gynecological cancer (incl. uterus, cervix, ovaries) Kidney cancer (incl. Wilm's tumor) Liver cancer (incl. hepatocellular carcinoma) Lung cancer (incl. lung, pleura) Lymphoma (incl. lymphoma, Hodgkins, Non-Hodgkins, malignant lymphoma in children) Male cancers (incl. penis, prostate, testicle) Multiple myeloma Nasal cancer Skin cancer, basal cell and squamous cell carcinoma (incl. melanoma/birthmark) Stomach cancer (incl. stomach, esophagus, pancreas Throat Cancer (incl. mouth and throat, sinus cancer) Other forms of cancer
Disease interest: Other (please specify)
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