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Register for Trial Information
Section 1: Contact Information
First Name:
Last Name:
Address:
City:
State/Province:
Zip Code:
Country:
Phone Number:
E-mail Address:
Section 2: Cancer Information
Type Of Cancer:
If Lung Cancer: Small Cell Non Small Cell Unknown
Stage of Cancer: (please check the one that applies.) Stage I
Stage II
Stage III Stage IV
Unknown
If Stage IV, to where has the cancer spread? (Please check all that apply.) Brain
Bone
Marrow
Lungs
Liver Lymph Nodes
Other (Please describe below.)
When was the cancer first diagnosed? Month  Year
Past and current chemotherapy treatments (Please describe below.)
Past Treatments? (Please check all that apply.)
Radiation (Enter exact site of the body where delivered.)
Surgery
Other (please describe below.)
Current Treatments? (Please check all that apply.)
Radiation (Enter exact site of the body where delivered.)
Surgery
Other (please describe below.)
When was your last cancer treatment? Month  Year
Are you currently in treatment? Yes  No
Has your cancer progressed or responded to the latest treatment?
Section 3: Additional Patient Information
Name of person with cancer:
Age of person with cancer:
Gender of person with cancer: M  F
Will patient travel for treatment? 50 to 100 Miles
100 to 250 Miles
Anywhere in the USA
Anywhere in the world
What cancer center has patient been seen at?
What studies, if any, have been offered to patient?
Additional Comments
E-mail Address or Fax Number for Trial Information
To Make Donation