1. 1) Please fill out this form and return in Word format if possible. You can leave areas blank that are not applicable. Fax form to (312) 227-9756

2. 2) Please send/fax: OR reports, Path reports, Imaging reports and any other clinical notes that apply.

3. 3) Imaging can be sent via LifeImage or FedEx. Contact [email protected] if you need a link/address.

4. 4) Please provide Pathology slides which should be sent to: BTB/Marian Stevenson, Department of Pathology,

5. Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 East Chicago Avenue, Box #17, Chicago, IL 60611, Tel: 312-227-3996

Name:

DOB:

Sex:

Requestor’s Name/Fax:

Name

Fax:

Phone:

Reason for Review/Questions:

Center/s Providing Treatment:

Neurosurgeon:

Oncologist:

Rad Onc:

Primary Care Provider:

Name:

Fax:

Diagnosis Date:

Brief History:

Surgery (Y/N): Type/Location/Extent/Dates:

Shunt (Y/N)? Type:

Chemo (Y/N): Protocol/Drugs/Dates:

Radiation (Y/N): Site/Type/Dose/Dates:

Current clinical status:

Complications:

Subspecialty Involvement (Endo, Neuro, Ophtho, etc.):

Recurrences (Y/N): Date/s:

Diagnosis/Pathology:

Other Testing: (Cytology/ Endocrine/Tumor Markers):

Tumor Location Primary:

Location of any metastatic disease:

Current Imaging:

Imaging/OR/Signif findings:

(Please list chronologically)

Other concerns: