Patient Data Request
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Atypical Teratoid/Rhabdoid Tumor (AT/RT) Patient Data Request

Registry ID # __________________________________________

Patient initials _________________________________________

DOB ________________________________________________

1� tumor site _________________________________________

Date of Diagnosis _____________________________________

Age at Diagnosis (in months) ____________________________

Gender ________

Race __________

Institution _____________________________________________

Pathologist ___________________________________________

Phone # _____________________________________________

Oncologist ___________________________________________

Phone # _____________________________________________

Send patient clinical information to:
Joanne Hilden, M.D./Sharon Meerbaum, B.S., C.C.R.P.
The Children's Hospital at the Cleveland Clinic
Dept of Pediatric Hem/Onc S-20
Cleveland Clinic Foundation
9500 Euclid Avenue
Cleveland, OH 44195
Phone: 216/444-8407 or 216/444-8640
Fax: 216/444-5925

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