Families with two or more cases of glioma are eligible to participate in the Gliogene study. All information that you provide, as well as your blood sample results will be kept completely confidential. No one outside of this study may have access to your information without your permission.

We have received a certificate of confidentiality from the National Institute of Health which protects the information your provide for this study. Please complete and submit the form below.

Contact Information

Full name

Address

Please provide us with your street address.

Address

Family History

Please indicate how many members of your family have been diagnosed with a brain tumor.
In continuation to the question above, what is the relation of each member to you?
How many members of your family possess other types of cancer?
Please list the other types of cancer in your family, and place an (F) for father's side, or (M) for mother's side beside each.
What is the relationship of each member designated as having "other type of cancer" to you?

Additional Comments

Please tell us about any additional information you wish to disclose.