GOG Web Menu Account Request Form

All users requesting GOG Web Menu accounts, no matter what the access level, MUST be in the GOG roster before an account can be created.  If you have any questions about roster information call Shawn Griffin at the GOG Admin Office at (215) 854-0770.  Click here for the GOG roster update request form. Everyone dealing with GOG data needs a username and password for a GOG Web Menu account.

Each institution must have at least one person defined for each access level. It is recommended that more than one person be allocated registration access.

Please fax the completed form to 716-845-8393 Attn: User Support

Each person below will be contacted to receive their GOG Web Menu username and password. Please contact the GOG Statistical & Data Center at 716-845-7767 or support@gogstats.org with questions.

New User

Name:          Telephone #:     Fax #:

  GOG Institution Name:                                            Patient Registration Forms Tracking Report Web Data Entry 

Additional  Users

Name:   Patient Registration Forms Tracking Web Data Entry

Name:   Patient Registration Forms Tracking Web Data Entry

Name:   Patient Registration Forms Tracking Web Data Entry

Name:   Patient Registration Forms Tracking Web Data Entry

The web patient registration process sends token receipts by email to staff with Registration Access. If you need additional staff notified by email for each patient registration, list them below:

Name:  Email: 

Name:  Email: 

GOG offers another option of sending all patient registration email to a single address.  This address would be an email distribution list that your site would manage. If you would like all email sent to a single email address please enter the email address below:

Email: 

Your Signature: