Treatment Center Listing Application

Page One

Thank you for your interest in including your medical facility on the Cutaneous Lymphoma Foundation's website. Our goal is to develop a long term relationship with the facilities we list so that together we can best serve the cutaneous lymphoma patient community.

As a first step, please provide the following introductory information and we will be in contact to learn more about your facility and its services.

1. Submission Date This question requires a valid date format of MM/DD/YYYY.

calendar

3. General Facility Information

Name of Medical Facility
Street Address
Address 2
City
State/Province
Country
Postal Code
Website link

4. Clinician requesting listing on the CL Foundation website *This question is required.

First Name

Last Name

Professional Suffix

Title

Email Address

Phone Number

5. If different from above, the primary contact responsible for keeping information regarding the website listing accurate and up-to-date:

	First Name	Last Name	Email	Phone
	First Name	Last Name	Email	Phone	Contact	First Name	Last Name	Email	Phone

Additional Information to Provide

6. Please upload a copy of cutaneous lymphoma physician's CV. *This question is required.

File: {{filename}} delete

7. Professional Affiliations (Check all that apply)

American Academy of Dermatology
American Society of Hematology
American Society of Clinical Oncology
International Society of Cutaneous Lymphoma
United States Cutaneous Lymphoma Consortium
Other (Please List) Please enter an 'other' value for this selection.

By submitting your center's application, you agree to update your provider roster, contact information, and spectrum of services on an annual basis. Updates may be conducted by interview with the CL Foundation staff or electronically. Failure to update may jeopardize ongoing site listing.

Centers listed on the Cutaneous Lymphoma Foundation's website agree to provide patients with CL Foundation educational materials directly or via website referral.