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Phase I Clinical Trial Form

Please fill out and submit the form below. If you have questions, contact the developmental therapeutics office at 314-286-1206 (phone) or 314-286-1239 (fax) or by e-mail at dtmail@siteman.wustl.edu. If the patient is not currently being seen at the Washington University School of Medicine, please fax or e-mail a physician summary and most recent labs.

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Patient Information
New Consult?  
First Name:  
Last Name:  
Date of Birth:  
Social Security Number:  
Address:  
City:  
State:  
ZIP Code:  
Phone Number:  
Alternate Number:  
E-mail Address  
GPS Profiling Performed?  

 

Disease Information 
Primary Site:  
Stage:  
Metastatic:  
Liver Mets:  
Second Primary:  
If yes, list the site:  
Active/Treated within two years:  
Status of second malignancy:  

 

Medical Information

 

Performance Status:  
Allergies:  
Diabetes (Any Type):  
Brain Mets:  
If yes, symptomatic:  
History of cardiac disease:  
Cardiac event within 6 months:  
If yes, specify:    
Does the patient use any of the following:  

 

Treatment Information
Date of last treatment:    [None] Select a Date Delete the Date
Number of prior therapies:  
Any chronic toxicities greater or equal to Grade 2:  
Date/Treatment:    
Date/Treatment:    
Date/Treatment:    
Date/Treatment:    
Date/Treatment:    
Referring Doctor:  
Date:    [None] Select a Date Delete the Date
Doctor's Phone Number:  
Form completed by:  

DT Policy: The DT team will screen patients for all available protocol slots in the order in which the patient intake form is completed and submitted for review; expected turnaround time is 2 business days. Once a patient is found to be preliminarily eligible for any study, the DT team will contact the clinical team to inform them of what studies the patient may qualify for. Patients may not consent/screen for a trial until a slot has been identified for that patient. Patients must be able to consent and begin screening within one week of notification of the open slot. Initial insurance checks will be performed by the DT team; however, the clinical team is responsible for completing any appeals if coverage is initially denied. Following initial insurance denial, any held slot will be released to the next person on the wait list.