Make an enquiry

Thank you for contacting Proton International London regarding proton beam therapy at University College Hospital. We understand that time is critical when dealing with a cancer diagnosis. The information requested in this form is essential for determining your eligibility for proton beam therapy. To avoid any delays, please complete as much of the form as possible. We aim to respond promptly to your enquiry.

If you would like to make a general enquiry please visit our contact us page.

Patient Information Enquiry Form

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Thank you for contacting Proton International London regarding proton beam therapy at University College Hospital. We understand that time is of the essence when living with a cancer diagnosis. This form contains all the information we need to determine your eligibility for proton beam therapy. To avoid any delays, please complete as much of the information as possible. We aim to respond promptly to your enquiry.

About you

Your Name(Required)

First Last

Your Email Address(Required)

Email Address Confirm Email Address

Your Phone(Required)

Patient Information

First Last

Date Of Birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please confirm your relationship with the patient

Cancer/tumour diagnosis(Required)

What are you requesting from us(Required)

Other

Please confirm the nature of your enquiry

How will you/the patient fund their consultation and/or treatment?

Please forward the following as Word or PDF documents (please avoid sending photographs of documents):

Medical reports from doctors currently treating the patient | PET scan/CT scan/MRI scan/x-ray imaging reports | Histopathology reports (following surgery/biopsy procedure)Operation notes/details| Imaging on disc (CD, DVD) or transferred electronically | Details of treatment already received, if known: Chemotherapy – names of drugs, number of cycles, dates of treatment | Radiotherapy –dose and number of fractions, dates of treatment | If you are unable to upload, please send all documents via email to padmin@protonintlondon.com

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Accepted file types: jpg, gif, png, pdf, docx, doc, Max. file size: 50 MB.

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Your enquiry

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Please note that if you attach multiple files to our enquiry form, the form may take longer to submit. Kindly click the submit button only once and wait for the confirmation screen.

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Contact Proton International London

For full details on how to find our centre, as well as our contact details and address please visit the ‘Contact us’ page.

Cancers we treat