Your details
We will use the details you provide to send your Information Pack, any other resources you request and any relevant information in the future.
Please note: if you are a healthcare professional,
please complete this form.
Title
Please select...
Mr
Ms
Miss
Mrs
Mx
Dr
Prof
Rev
First name
Last name
Email address
Phone number
Phone type
Mobile
Home
Work
Your date of birth
How did you hear about our Information Pack?
Please select...
Social Media
Search Engine (i.e. Google)
Through a family member/friend/colleague
Recommended by a health professional
Recommended by another charity
The Brain Tumour Charity website
Email from The Charity
From The Brain Tumour Charity staff member
The Grey Matters
Other
Please tell us how you heard about our Information Pack
Have you been diagnosed with a brain tumour?
Yes
No
How old is the person diagnosed with a brain tumour:
Adult (over 30)
Young Adult (18-30)
Teenager (16-17)
Child (under 16)
What is your relationship to this person
I'm their
Please select...
Partner
Parent
Child
Sibling
Step-parent
Step-child
Grandparent
Relative
Friend
Colleague
Pupil
Legal guardian
Healthcare professional
Other
Please tell us your relationship
Details of the person diagnosed with a brain tumour
Title
Please select...
Mr
Ms
Miss
Mrs
Mx
Dr
Prof
Sir
Dame
Lord
Lady
Baroness
Rev
Rt. Hon
Cllr
Duke
Duchess
Cmdr
First name
Last name
Gender
Please select...
Male
Female
Other
About the diagnosis
Health privacy notice
If you are happy to share information about yours or a loved one's brain tumour diagnosis with us it will help us provide you with relevant information and support, as well as monitor our services and make improvements in future.
Tumour type (if known)
Please select...
Acoustic neuroma (also known as vestibular schwannoma)
Anaplastic astrocytoma
Astrocytoma
AT/RT (atypical teratoid/rhabdoid tumour)
Brain stem glioma
Choroid plexus tumour
CNS lymphoma
Craniopharyngioma
Diffuse astrocytoma
DIPG (also known as diffuse midline glioma)
Embryonal tumours (including PNETs)
Ependymoma
Familial tumour syndromes (including NF1/2 and schwannomatosis)
Fibrillary astrocytoma
Ganglioglioma
Germ Cell Tumour
Glioblastoma (GBM)
Haemangioblastoma
Medulloblastoma
Meningioma
Metastatic Brain Tumour
Mixed Glioma
Oligodendroglioma
Optic nerve glioma
Pilocytic Astrocytoma
Pineal region tumour (including pineoblastoma)
Pituitary tumour
Schwannomas
Spinal cord tumour
Unspecified glioma
Other
Unknown
Please tell us what type of brain tumour:
Tumour grade (if known)
Low Grade (1-2)
High Grade (3-4)
Date of diagnosis (if known)
Recency of diagnosis
Within the last 2 weeks
Within the last 4 weeks
More than 4 weeks ago
Where is your primary hospital
Please select...
Aberdeen - Aberdeen Royal Infirmary
Belfast - Royal Victoria Hospital
Birmingham - New Queen Elizabeth Hospital
Bristol - Bristol Royal Infirmary
Bristol - Frenchay Hospital
Bristol - Southmead Hospital
Cambridge - Addenbrooke's Hospital
Cardiff - University Hospital of Wales
Cardiff - Velindre Hospital
Coventry - University Hospitals Coventry and Warwickshire
Denbigshire - Glan Clwyd Hospital
Derby - Derby Royal Infirmary
Dublin - Beaumont Hospital
Dundee - Ninewells Hospital
Edinburgh - Edinburgh Cancer Centre at Western General Hospital
Edinburgh - Western General Hospital
Exeter - The Royal Devon and Exeter Hospital
Glasgow - Queen Elizabeth Hospital
Glasgow - Southern General Hospital
Gloucester - Gloucestershire Royal
Hull - Hull Royal Infirmary
Ipswich - Ipswich Hospital
Leeds - Leeds Gamma Knife Centre
Leeds - Leeds General Infirmary
Leeds - St James's University Hospital
Leicester - Leicester Royal Infirmary
Lincoln - Lincoln County Hospital
Liverpool - Alder Hey Children's Hospital
Liverpool - The Clatterbridge Cancer Centre
Liverpool - The Walton Centre for Neurology and Neurosurgery
London - Barts and London Centre for Neurosciences
London - Bupa Cromwell Hospital
London - Charing Cross Hospital
London - Guy's Hospital
London - Hammersmith Hospital
London - Harley Street University College Hospital
London - King College Hospital
London - Lister Hospital
London - Moorfields Eye Hospital
London - National Hospital for Neurology and Neurosurgery
London - Royal Free Hospital
London - Royal London Hospital
London - Royal Marsden Hospital
London - St. George's Hospital
London - St. Mary’s Hospital
London - St. Thomas’ Hospital
London - The Cyber Knife Centre
London - University College Hospital
London - Wellington’s Hospital
Macclesfield - Macclesfield District General Hospital
Manchester - The Christie
Manchester - The Royal Manchester Children’s Hospital
Middlesbrough - James Cook University Hospital
Newcastle - Freeman Hospital
Newcastle - Royal Victoria Infirmary
Norwich - Norfolk and Norwich Hospital
Nottingham - Queens Medical Centre
Oxford - John Radcliffe Hospital
Plymouth - Derriford Hospital
Poole - Poole General Hospital
Preston - Royal Preston Hospital
Romford - Queen’s Hospital
Salford - Salford Royal Hospital
Sheffield - Royal Hallamshire Hospital
Southampton - Southampton General Hospital
Stoke - University Hospital of North Staffordshire
Sunderland - Sunderland Royal Hospital
Sutton - Royal Marsden Hospital
Swansea - Morriston Hospital of Swansea
Swansea - Singleton Hospital
Swindon - The Great Western Hospital Swindon
Taunton - Mugrove Park
Truro - The Royal Cornwall Hospital
West Sussex - Hurstwood Park
Wolverhampton - New Cross Hospital
York - The York Hospital
Unknown
Other
Please tell us your hospital
You will receive your Information Pack by email on completion of this form.
Please note: Information Packs are only by available by post
in the United Kingdom
.
Would you prefer to receive your Information Pack by post?
Yes
No
Please confirm if you are a UK resident
Yes
About the child's diagnosis
Health privacy notice
If you are happy to share information about your child's brain tumour with us it will help us provide you with relevant information and support, as well as monitor our services and make improvements in future.
Child's first name
Child's last name
Child's date of birth
Child's tumour type (if known)
Please select...
Acoustic neuroma (also known as vestibular schwannoma)
Anaplastic astrocytoma
Astrocytoma
AT/RT (atypical teratoid/rhabdoid tumour)
Brain stem glioma
Choroid plexus tumour
CNS lymphoma
Craniopharyngioma
Diffuse astrocytoma
DIPG (also known as diffuse midline glioma)
Embryonal tumours (including PNETs)
Ependymoma
Familial tumour syndromes (including NF1/2 and schwannomatosis)
Fibrillary astrocytoma
Ganglioglioma
Germ Cell Tumour
Glioblastoma (GBM)
Haemangioblastoma
Medulloblastoma
Meningioma
Metastatic Brain Tumour
Mixed Glioma
Oligodendroglioma
Optic nerve glioma
Pilocytic Astrocytoma
Pineal region tumour (including pineoblastoma)
Pituitary tumour
Schwannomas
Spinal cord tumour
Unspecified glioma
Other
Unknown
Please tell us what type of brain tumour
Child's tumour grade (if known)
Low Grade (1-2)
High Grade (3-4)
Child's date of diagnosis (if known)
Recency of your child's diagnosis
Within the last 2 weeks
Within the last 4 weeks
More than 4 weeks ago
Where is your child's primary hospital
Please select...
Aberdeen - Aberdeen Royal Infirmary
Belfast - Royal Victoria Hospital
Birmingham - New Queen Elizabeth Hospital
Bristol - Bristol Royal Infirmary
Bristol - Frenchay Hospital
Bristol - Southmead Hospital
Cambridge - Addenbrooke's Hospital
Cardiff - University Hospital of Wales
Cardiff - Velindre Hospital
Coventry - University Hospitals Coventry and Warwickshire
Denbigshire - Glan Clwyd Hospital
Derby - Derby Royal Infirmary
Dublin - Beaumont Hospital
Dundee - Ninewells Hospital
Edinburgh - Edinburgh Cancer Centre at Western General Hospital
Edinburgh - Western General Hospital
Exeter - The Royal Devon and Exeter Hospital
Glasgow - Queen Elizabeth Hospital
Glasgow - Southern General Hospital
Gloucester - Gloucestershire Royal
Hull - Hull Royal Infirmary
Ipswich - Ipswich Hospital
Leeds - Leeds Gamma Knife Centre
Leeds - Leeds General Infirmary
Leeds - St James's University Hospital
Leicester - Leicester Royal Infirmary
Lincoln - Lincoln County Hospital
Liverpool - Alder Hey Children's Hospital
Liverpool - The Clatterbridge Cancer Centre
Liverpool - The Walton Centre for Neurology and Neurosurgery
London - Barts and London Centre for Neurosciences
London - Bupa Cromwell Hospital
London - Charing Cross Hospital
London - Guy's Hospital
London - Hammersmith Hospital
London - Harley Street University College Hospital
London - King College Hospital
London - Lister Hospital
London - Moorfields Eye Hospital
London - National Hospital for Neurology and Neurosurgery
London - Royal Free Hospital
London - Royal London Hospital
London - Royal Marsden Hospital
London - St. George's Hospital
London - St. Mary’s Hospital
London - St. Thomas’ Hospital
London - The Cyber Knife Centre
London - University College Hospital
London - Wellington’s Hospital
Macclesfield - Macclesfield District General Hospital
Manchester - The Christie
Manchester - The Royal Manchester Children’s Hospital
Middlesbrough - James Cook University Hospital
Newcastle - Freeman Hospital
Newcastle - Royal Victoria Infirmary
Norwich - Norfolk and Norwich Hospital
Nottingham - Queens Medical Centre
Oxford - John Radcliffe Hospital
Plymouth - Derriford Hospital
Poole - Poole General Hospital
Preston - Royal Preston Hospital
Romford - Queen’s Hospital
Salford - Salford Royal Hospital
Sheffield - Royal Hallamshire Hospital
Southampton - Southampton General Hospital
Stoke - University Hospital of North Staffordshire
Sunderland - Sunderland Royal Hospital
Sutton - Royal Marsden Hospital
Swansea - Morriston Hospital of Swansea
Swansea - Singleton Hospital
Swindon - The Great Western Hospital Swindon
Taunton - Mugrove Park
Truro - The Royal Cornwall Hospital
West Sussex - Hurstwood Park
Wolverhampton - New Cross Hospital
York - The York Hospital
Unknown
Other
Please tell us your child's hospital
You will receive your Information Pack by email on completion of this form.
Please note: Information Packs are only by available by post
in the United Kingdom
.
Would you prefer to receive your Information Pack by post?
Yes
No
Would you like a Brainy Bag for your child?
Yes
No
Please confirm if you are a UK resident
Yes
Your address
Please note we only post within the UK. Any requests from outside the UK will be sent information via email.
Postcode
Address line 1
Address line 2
Town / City
County
Stay in touch
We are sorry we can't send you your Information pack by post, however all your information will be included in your information email.
We are sorry we can't send you your Information pack and Brainy Bag by post, however all your information will be included in your information email.
Your support is helping to save lives, we look forward to keeping in touch with you by post and phone with information about research, support services and how you can get involved with our life saving work, for example through fundraising, campaigning or volunteering.
Would you like to hear from us by email?
Yes
No
Would you like to hear from us by sms?
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No
Please tell us your mobile phone number
We promise to keep your details safe and never sell or swap them with anyone. Our
privacy policy
explains how we keep this promise. If you don't want to hear from us, or you change your mind about how we contact you, please email
enquiries@thebraintumourcharity.org
or call 01252 237792