Title

First name

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Have you been diagnosed with a brain tumour?

YesNo

What is your relationship to the person with a brain tumour?

I am their

When was the diagnosis?

Within the last 2 weeksWithin the last 4 weeksMore than 4 weeks ago

What treatment are you currently receiving?

What treatment are they currently receiving?

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Your support is helping to save lives, we look forward to keeping in touch with you with information about research, support services and how you can get involved with our life saving work, for example through fundraising, campaigning or volunteering.

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