CareLine Contact Form Title Please select…Mr.Ms.Mrs.MissDr. First Name Last Name Email Address Phone Number Zip/Postal Code Which best describes you? Please select…Brain tumor patient/survivorFamily member or friendHealth care professionalOther Who was diagnosed with a brain tumor? Please select…MyselfSpouseParentSiblingMy child (age 0-17)My child (age 18+)Significant other / PartnerFriendPatient or caregiver (for health care professionals)Other Other (Fill in) Brain Tumor Type Please select…Glioblastoma / Astrocytoma IVMeningiomaAcoustic Neuroma / Vestibular SchwannomaAstrocytoma, PilocyticAstrocytoma, DiffuseAstrocytoma, AnaplasticAstrocytoma, OtherBenignCraniopharyngiomaCystEpendymomaGliomaLymphoma / Central Nervous System LymphomaMedulloblastomaMetastatic Brain TumorOligodendrogliomaOligoastrocytoma or Mixed GliomaPituitary TumorSpinal Cord TumorAwaiting pathology reportI don’t knowOther Other (Fill in) Tumor Grade Please select…IIIIIIIV Date of Diagnosis (If unsure of date, please estimate) Question or Comment Need assistance with this form?