Register

Request for a Professional Account

Healthcare professionals, clinicians, nurses, and researchers can obtain a professional account for research purposes.

Please complete the forms below to request access to the Lung Cancer Registry.

User Information

Your First Name (Account Holder) (Required):

Your Last Name (Account Holder) (Required):

Username (Required):

Password (Required):

Re-enter Password (Required):

Company/Institution (Required):

Department:

Job Title (Required):

Contact Information

Email (Required):

Confirm Email (Required):

Address Line 1 (Required):

Address Line 2:

City (Required):

State (USA Only):

Postal/Zip Code (Required):

Country (Required):

Phone (Work) (Required):

Phone (Cell):

Nature of Request

To request access to de-identified data within the Lung Cancer Registry please indicate the specific question or areas of information you are interested in addressing with the Lung Cancer Registry data.

Nature of Request (Required):
If you would like to submit a proposal for a research study to be conducted with the Lung Cancer Registry – please see the FAQ for further information on submission.

Permission

In applying for access to The Lung Cancer Registry Professional Portal, you must agree to the following:
If approved, your username and password should be used ethically and responsibly, only for yourself and those in your organization with similar intent
If you wish to publicly share an analysis of the information included in The Lung Cancer Registry, you will ensure that the information is being used in an ethical manner and notify The Lung Cancer Registry of the data you plan to share to help us track outcomes. Publicly published findings should credit The Lung Cancer Registry.
The Lung Cancer Registry will communicate outcomes from The Lung Cancer Registry data back to registered patient users.
The Lung Cancer Registry cannot be held accountable for the accuracy of information provided by users.

I agree to the Professional Access Terms and Conditions (Required):

I agree to the Lung Cancer Registry Terms and Conditions (Required):

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