REFERRAL FORM - Pancreatic Cancer Action Network

January 15, 2018 | Author: Anonymous | Category: N/A
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REFERRAL FORM Know Your Tumor provides eligible pancreatic cancer patients and their oncologists with information about the biology of their tumor to potentially aid in treatment decision making. The Pancreatic Cancer Action Network works with a leading personalized cancer therapy company, Perthera, to coordinate tumor analysis, expert interpretation and the creation of a report listing potential treatment options, including clinical trials. Patients and/ or their loved ones can also choose to share information from the report with those researching pancreatic cancer through the Pancreatic Cancer Action Network Patient Registry. If you are a pancreatic cancer patient who is interested in learning more about Know Your Tumor and the Patient Registry, please complete the form below. I would like a Patient Central Associate at the Pancreatic Cancer Action Network to contact me about the Know Your Tumor service and the Patient Registry. (Optional) I give permission for the Pancreatic Cancer Action Network to update my doctor (and his/her staff) regarding my enrollment status in Know Your Tumor. 

Patient’s Full Name Phone Email  Patient Signature Date

In order for a patient to enroll in this service, we need confirmation from the treating doctor that the above patient meets the following criteria: 1. Diagnosis of a pancreatic malignancy 2. No signs of progression or impending need to change treatment, or understands that Know Your Tumor cannot be used for immediate treatment planning (Note: It requires 25-45 days from receipt of tissue for the Perthera report to be completed and delivered to the patient and physician) 3. Tissue is obtainable: • Newly obtained biopsy, 4-6 cores with 18-20 gauge needle preferred • From accessible metastatic site • From primary if biopsy acquisition is deemed an acceptable risk • Surgical specimen • If post-surgery, within 12 months of resection with no other source of tissue available 4. Patient resides in the U.S. or Canada 5. Patient or close loved one is able to read and speak English or Spanish 6. Patient is not imprisoned To confirm that your patient meets the above criteria, please sign below. I certify that the patient above meets the above criteria to enroll in Know Your Tumor.  Physician’s Name

Practice/Institution Name

 Physician’s Email Address (to receive updates regarding your patient’s Know Your Tumor enrollment status)  Physician Signature

Note to healthcare professional: Completion of this form activates our enrollment process but does not guarantee participation in Know Your Tumor.

In partnership with

Please complete this form with your pancreatic cancer patient. Upon receipt of this form by the Pancreatic Cancer Action Network, the patient will receive a phone call from a Patient Central Associate to learn more about the service and to determine eligibility. Not all pancreatic cancer patients are eligible for this service. Send this form to Patient Central by fax at 310-496-0664 or by email to [email protected]. Pancreatic Cancer Action Network | 1500 Rosecrans Ave., Ste. 200 | Manhattan Beach, CA 90266 |

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