Appointment Request Form

Are you the patient? *

Yes

Is the patient a US citizen or a lawful permanent resident of the US? *

Yes

Has the patient had an appointment at the Duke Cancer Institute within the last 3 years? *

Yes

International Patient Referrals

To refer an international patient, please complete the form on this page: https://redcap.duke.edu/redcap/surveys/?s=MPRRKEXJT8.

Returning Patients

Please log in to MyChart (https://www.dukemychart.org) to request a new appointment. If you haven't registered for MyChart yet, call 919-620-4555 or 800-782-6945 for an activation code, registration (https://www.dukemychart.org/home/accesscheck.asp) is quick and easy.

Contact Information

First Name *

Last Name *

Phone Number *

Phone Type *

Email *

Confirm Email *

Patient Relationship *

Patient Information

Patient First Name *

Patient Middle Initial

Patient Last Name *

Street Address *

City *

State *

Zip/Postal Code *

Country *

Phone Number *

Phone Type *

Email *

Confirm Email *

Gender *

I Self-Describe as... *

Date of Birth *

Month

Day

Year

Medical Information

What are you interested in? *

Have you been told you have a possible cancer diagnosis? *

What is your diagnosis? *

Preferred Treatment Location *

Other Diagnosis *

Posted: July 27, 2020

International Patient Referrals

Returning Patients

Contact Information

Patient Information

Medical Information

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