Clinical Trial Support Center

Clinical Trial Support Center Referral Form

Please complete the following information.  By completing and submitting this form, you represent you are authorized to share the information below, including the patient's medical information, with LLS. 
Upon receipt, an LLS Clinical Trial Nurse Navigator or Information Specialist will reach out to work with you.  This service is not a substitute for medical advice.  You should discuss what you learn with your treatment team.
 
For any questions, contact the Information Resource Center at 1-800-955-4572. 
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Patient's Disease/ Diagnosis Information:

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GRADE
 
ECOG PERFORMANCE STATUS
 
0
 
Fully active, able to carry on all pre-disease performance without restriction
 
1
 
Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work
 
2
 
Ambulatory and capable of all selfcare but unable to carry out any work activities; up and about more than 50% of waking hours
 
3
 
Capable of only limited selfcare; confined to bed or chair more than 50% of waking hours
 
4
 
Completely disabled; cannot carry on any selfcare; totally confined to bed or chair
 
Type of insurance?
By checking this box, I agree that LLS may add my personal medical information to its Patient Access mailing list where it may be used to contact me about services offered by LLS. If I am completing this form on behalf of another individual, I represent that I am legally authorized to provide consent to LLS’s marketing practices on behalf of that individual. *
The clinical trials to which LLS will assist in matching patients are those listed on ClinicalTrials.gov, a registry provided by the U.S. National Library of Medicine (NLM).  LLS and NLM have not evaluated the studies appearing on the registry to confirm that they are being conducted in accordance with all applicable laws and regulations or to confirm the safety or validity of the studies.  Not all studies are regulated and/or reviewed by the U.S. Food and Drug Administration or other governmental entities.  The clinical studies may be sponsored or funded by a broad range of public and private organizations around the world, including for-profit companies.  The clinical trial information provided by LLS is for informational purposes only and is not intended to be medical advice.  The information should be discussed with your health care team.  Before participating in a study, you should discuss all options with your health care provider, as well as the risks and potential benefits of participation.