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Wednesday, September 08, 2010
Home Treatment Options Melanoma Information Centers of Excellence Trial Finder Support Services Community Education News/Resource Center
Centers of Excellence>>MCE Application  
 
Application for MCE   
Institution Name
Address 1
Address 2
City
State
Postal Code
Fax Number
Email Address
Web Site URL
Our Center Treats Melanoma (stages I through IV) amoung collaborative Clinicians.
Our center has the equivalent of 0.5 full time employed physicians treating melanoma (i.e., 1 doctor with 50% of caseload being melanoma, 2 doctors with .25% of caseload being melanoma, etc.)
Name of Physician
Phone No.
Contact Person:
Percentage of Caseload being melanoma
Name of 2nd Physician
Contact Person (2nd Dr.)
Phone No. (2nd)
Percentage of Caseload being melanoma (2nd Dr.)
Our center provides multiple disciplines under one roof or working agreements between collaborating groups that provide patients with seamless care in dermatology, surgery (general or surgical oncology), medical oncology, and radiation oncology.
Our center has two or more melanoma specific clinical trials actively recruiting patients.
Please list the name of two of your active trials.
(Please keep response to less than 400 characters)
The following person is our center’s designated Melanoma Hope Network contact person/team leader for referrals and other information needs. (Can be a doctor, nurse or other office personnel.) Please provide all contact information - especially e-mail !
(Please keep response to less than 400 characters)
Please provide a short paragraph that describes the support care services that are available to your patients and or their families. These services may be provided directly by your center or via collaborative arrangements with other support agencies.
(Please keep response to less than 400 characters)
Please provide a short paragraph that describes how your center participates in community education efforts either locally or nationally
(Please keep response to less than 400 characters)
Name and e-mail of person completing this form
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