Early Stage Breast Cancer Trial Application

Name

Email

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Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date Of Birth

Best time to call

Nearest Panthera Clinic

Do you consent to the collection and processing of your personal data in accordance with the GDPR for the purposes stated in our privacy policy?

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* To proceed with your pre-screening, we need your consent to collect and process your personal data in accordance with the GDPR. Without this consent, we cannot save your initial data or determine your eligibility, which would result in an incomplete application. Please select 'Yes' to consent. For more information or assistance, contact our team.

Are you over the age of 18?

Yes
No

Have you had a diagnosis of breast cancer?

Yes
No

Was the breast cancer confined to the breast and lymph nodes only (i.e no spread of cancer to other organs)?

Yes
No

Have you had surgery to remove the breast tumour and lymph nodes?

Yes
No

Is your breast cancer currently in remission?

Yes
No

Are you currently taking any hormone therapies - i.e. Letrozole, Anastrazole, Tamoxifen, Exemastane - as part of your breast cancer treatment?

Yes
No

Have you been on this medication for at least 21 months but less than 5 years?

Yes
No

Are you currently taking a medication called fulvestrant

Yes
No

Are you currently pregnant, breastfeeding or planning on becoming pregnant in the next 10 years? ( If Female )

Yes
No

Are you currently receiving treatment for any other type of cancer?

Yes
No

Have you ever experienced a blood clot in your leg or lungs?

Yes
No

Do you have a diagnosis of HIV, Hepatitis B or Hepatitis C

Yes
No

Are you currently taking part in any other clinical trial involving the testing of a medication or device?

Yes
No

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