PLEASE NOTE

That all EORTC modules are designed to be used in conjunction with the QLQ-C30 (Core questionnaire) and should NOT be used alone.

Title (eg Dr., Mr., Ms, etc)
First Name
Last Name
Name of Hospital or Institution
Address
State/County
Postal code
Country
Telephone Number
Fax Number
E-mail address
Number and title of protocol
Where did you hear about the EORTC QLQ-C30?
If "Other", please specify: