Skin Cancer Eligibility Test - Houston
Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
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What type of skin cancer have you been diagnosed with?
SCC (Squamous Cell Carcinoma)
BCC (Basal Cell Carcinoma)
Melanoma
MCC (Merkel Cell Carcinoma)
What is the current condition of the tumor? Circle the most accurate answer.
I have a cancerous tumor that has not been completely removed
I do not have a cancerous tumor and I am looking for a preventive treatment
What is the location of the cancerous tumor that needs treatment? Click on the most accurate answer to the best of your knowledge.
Head/Face (cheek, ear, nose, forehead, skull, scalp etc...)
Rest of the body (Limbs - hands & feet, fingers etc...)
Internal organs (pancreas, lung, stomach, esophagus, cervix, etc...)
Oral cavity (inside lips/mouth, tongue, throat etc...)
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