National Cancer Institute - Cancer.gov

Surgery Branch Immunotherapy Clinic Application

This Application is the first step in a multi-step process for being considered for participation in any immunotherapy treatment trial at NCI surgery branch.  Also, you may visit CCR clinical trials to learn about some other options. If you have any questions or have an issue filling out this form, please contact our team at 1-866-820-4505 or IRC@nih.gov

Application Information
Contact Information
(mm/dd/yyyy)
Type of Phone?
Preliminary Questions
(month/year)
Are you currently on treatment for your cancer?
Did the doctor change your treatment based on progression of disease from your last scan?
Medical Information
Have you ever had a heart attack or heart disease?
Are you on any steroids, including asthma-type inhalers?
Do you have a KRAS G12V or KRAS G12D mutation?
Do you have a TP 53 mutation?
Do you have any stents or drains?
Have you ever had or currently have cancer in your brain?
Do you have any autoimmune conditions?
Do you have other health issues or other cancers?
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