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Treatment Center Directory Application

Page One

Thank you for your interest in listing your medical center as a multidisciplinary cutaneous lymphoma treatment center on the Cutaneous Lymphoma Foundation's website. The "multidisciplinary center" designation will apply to those centers where more than one medical specialty collaborates in the care of patients with cutaneous lymphoma. For those practices with one specialty, they will be designated as a practice that has an expertise in treating cutaneous lymphoma rather than a multidisciplinary center.

By completing and submitting the application form, you agree to update your information annually and to provide patients with the Cutaneous Lymphoma Foundation's educational materials either directly or via website referral.
Upon reviewing information provided on your website, please select which statement is true for your facility.
Please note: you will be required to provide current "who to contact for updates" information regardless of selection.
2. General Information
3. General Contacts
First Name Last Name Email Phone
Office Manager
Referral Contact
4. Contact Person to Verify Information - who is best person to contact for updates *This question is required.
Additional Information to Provide
Please upload a copy of lead cutaneous lymphoma physician's CV. *This question is required.
5. Professional Affiliations (Check all that apply)
6. Please upload a copy of any cutaneous lymphoma patient and/or marketing materials that are distributed from your office or center; please include any language and/or materials posted on your website.
7. Photo Image of Treatment Center (Optional)
Composition

Please check all that apply and provide names and credentials of providers for each category in the appropriate space below.
If you do not offer a particular service, please supply name(s) of the practices(s) or physicians(s) to which you refer patients.
8. Multidisciplinary Services Offered
Space Cell Delivered On SiteReferred to Collaborating Specialist/CenterN/A
Dermatological Oncology
Medical Oncology
Radiation Oncology
Dermatopathology
Integrative Medicine (Naturopathic Doctor)
Nursing
Social Work
Clinicians and Staff
9. Please provide the names, professional suffixes and specialty for clinicians and staff seeing cutaneous lymphoma patients.
Location Specialty First Name Last Name Professional Suffix
Onsite Referred
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
10. New Patients - please check any requirements needed before accepting a new patient
11. Services (Check all that apply)
  • * This question is required.
  • * This question is required.
  • * This question is required.
12. Therapies (Check all that apply.)
Space Cell Delivered On SiteReferred to Collaborating Specialist/CenterN/A
Total Skin Electron Beam Radiation Therapy
PUVA Phototherapy
Local Electron Beam Radiation Therapy
Surface Mold Computer-Optimized High-Dose-Rate Brachytherapy
Photopheresis
Infusion Therapy
Cutaneous Lymphojma Specific Systemic Therapies (ie. Interferon, Methotrexate, Bexarotene)
13. Collaborating Treatment Facilities for Referrals
Therapy Type Name of Referred Facility
1
2
3
4
5
6
14. Research Program (check all that apply)
15. Additional Services Provided (check all that apply):
This question requires a valid number format.
This question requires a valid number format.
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 CLF 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 CLF educational materials directly or via website referral.