All Saints Child Study Center Cook Children's Medical Harris Methodist HCA Medical Plaza John Peter Smith Medical Center Arlington TX Proton Therapy Center Other

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Patient Mother Father Sibling Grandparent Relative Friend of Family Step-Parent Parent's S.O. Patient's S.O. Unknown

Male Female Nonconforming Nonbinary Unborn Declined

Please select a response Aboriginal Arab/Middle Eastern Asian Black/African Descent East Indian First Nation Hispanic Latino Maori Multi-Racial Native American or Alaskan native Pacific Islander White/Caucasian Other Declined

Unvaccinated Vaccinated Prefers not to answer

Patient Mother Father Sibling Grandparent Relative Friend of Family Step-Parent Parent's S.O. Patient's S.O. Unknown

Male Female Nonconforming Nonbinary Unborn Declined

Please select a response Aboriginal Arab/Middle Eastern Asian Black/African Descent East Indian First Nation Hispanic Latino Maori Multi-Racial Native American or Alaskan native Pacific Islander White/Caucasian Other Declined

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