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Advanced Stage III/IV Cancer Patient Qualification Survey
Please complete this form to determine your eligibility for the Advanced Stage III/IV Cancer clinical trial.
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* Indicates required question
Email
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
Phone Number
*
###-###-####
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Are you 18 years of age or older?
*
Yes
No
When were you diagnosed with cancer?
*
Your answer
Can you provide medical documentation confirming your cancer diagnosis?
*
Yes
No
Please check one of the following below.
*
Stage 3 Breast
Stage 3 Lung
Stage 3 Ovarian
Stage 3 Prostate
Stage 4 Breast
Stage 4 Lung
Stage 4 Prostate
Stage 4 Ovarian
Other:
Required
Has your tumor been surgically removed?
*
Yes
No
What is your tumor status?
*
Stable
Progressive
Are you receiving regular blood transfusions?
Yes
No
Clear selection
Are you pregnant?
*
Yes
No
Are you willing to sign an informed consent to participate in this trial?
*
Yes
No
How did you hear about us?
*
Facebook
Instagram
Google
Website
Clinical Connection
StudyKik
Other:
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