National Cancer Institute - Cancer.gov

Medical Oncology Referral Office

This application is the first step in a multi-step process for being considered for participation in a clinical trial at the Center for Cancer Research, National Cancer Institute at the NIH Clinical Center in Bethesda, MD. If you have any questions or have an issue filling out this form, please contact our team at 1-888-624-1937 or nciinfo@mail.nih.gov.

Contact Information
This inquiry is for an adult or pediatric patient?:
Are you the patient:
Whats is your contact information?
Is the patient aware you are inquiring about a referral on their behalf to NIH?
Patient Information
Does the patient reside in the U.S.?
Medical Information
Is the patient:
Did the recent scan show progression of disease?
Does the patient have any autoimmune conditions?
Has the patient ever had or currently have cancer in the brain?
Has the patient received radiation therapy?
Does the patient already have other health issues or other cancers?
Is the patient interested in a specific trial?
Is the patient confined to bed or chair more than 50% of waking hours?
Oncologist Information
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