PATIENT REGISTRY | Pediatric + AYA Adenoid Cystic Carcinoma (ACC) — ACCKT

You Are Not Alone.

We are a small, compassionate group of families and fighters both young and grown who want to connect with other families and patients who know the unique journey of battling Pediatric ACC. Our collaboration not only helps us support one another on this rare journey, but allows us to aid ACC researchers and the cancer care community to learn more about our disease.
**Please help us by filling out our online registry.**

You are eligible to register if you fit one of these criteria:

You are a parent / primary caregiver of a child diagnosed with ACC between ages 0-20
OR
You are an adult patient originally diagnosed with ACC between age 0-20.

ACCKT PRELIMINARY PATIENT REGISTRY

Patient Name

First Name

Last Name

Your Name (If parent / caregiver)

First Name

Last Name

Email Address

City, State, Country

Patient Age at Diagnosis

Official Diagnosis | Please be detailed

Treating Hospital / Cancer Center

May We Contact You For More Information?

How Did You Find Us?

** If you are a patient under the age of 18, please have your parent or primary caregiver fill out the registry on your behalf.