Mott Logo

3D Tumor Replica Request Form

 

Submitting this form is only the first step in requesting a 3D replica of your child’s tumor. You must be also able to mail us a CD of CT or MRI images of your child's tumor. The mailing address will appear on screen after submitting this form. If you do not have a copy of CT or MRI scans showing your child's tumor, you can obtain one from your child’s medical team. Your medical provider may charge a fee for this CD.

 

First Name:
Last Name:
City :
State :  
Zip:
Email: