Providence Cancer Center - Clinical Trials Patient Interest Form  

 
  Please complete the items below to the best of your ability. Once completed, click “done” to send the form to the Providence Cancer Center Clinical Trials Department. The form will automatically be sent to to the department for assessment of possible clinical trials. Depending on the amount of information provided, Providence Cancer Center Clinical Trials Staff may request more information in the form of medical records.

Please be prepared to send the following documents: Oncology doctor’s history and physical, pathology reports, imaging reports, and most recent blood work lab results.

You will be contacted within 48 hours of form submission(during regular business hours).
   
 
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Physicians and Location:      
Physicians and Location:      
Physicians and Location:      
   
 
 
   
 
 
   
 
 
   
  Cancer diagnosis details
   
 
 
   
 
 
   
 
 
   
 
 
      
Treatment      
Treatment      
Treatment      
Treatment      
Treatment      
   
 
 
    
History of poor circulation    
High blood pressure    
Heart attack    
HIV or Aids    
Diabetes    
Breathing problems like asthma or emphysema    
Hepatitis (if yes, specify below)    
Anemia or low blood counts    
Stroke    
Thyroid problems    
Rheumatoid disorder    
Supplemental oxygen use    
Auto immune disorder (if yes, specify below)    
Current use of immuno-suppressive agents    
Kidney problems    
Taking blood thinners    
Have you had brain metastasis?    
   
 
 
   
 
 
   
  While you are waiting to hear from the Clinical Trials Department, please fax the following to 503-215-6725, Attn: Clinical Trials Screening
1. Any recent lab work (blood work)
2. Most recent doctor visit chart note
3. Pathology reports
   
 
 
   
 
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