Clinical Trials Search Request Form

The information contained in this form is used to provide the most relevant clinical trial options possible. We will be in touch with you after receiving this form. Please don’t hesitate to reach out with questions or concerns: ClinicalTrials@AlexsLemonade.org

Parent and Patient Contact Information

Parent’s First Name *

Parent’s Last Name *

Email Address *

Phone Number *

Patient’s First Name *

Patient’s Middle Initial

Patient’s Last Name *

Patient’s City

Patient’s State

Patient’s Country

Patient’s Date of Birth *

Year

Month

Day

Patient’s Gender

Diagnosis Information

How can we help you? *

Date of Diagnosis *

Year

Month

Day

Patient’s Diagnosis (include type and subtype if known and any other descriptive information pertinent to the search) *

Stage and/or Grade of Cancer

Has the patient relapsed and/or is the cancer refractory to care? *

Relapse Date

Year

Month

Day

If the patient has had other types of cancer, please list below along with date of diagnosis.

Additional Information

Healthcare Professional’s Hospital *

Healthcare Professional’s Name *

Healthcare Professional’s Title (oncologist, nurse practitioner, social worker, etc.) *

Is the patient's current oncologist actively participating in the clinical trial search? *

If the patient has enrolled in a clinical trial(s) previously, please list the name of the trial and the hospital.

How far would you be willing to travel for a clinical trial? *

Leave this field blank

Alex's Lemonade Stand Foundation for Childhood Cancer

Clinical Trials Search Request Form

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Kingsley Jackson