OncoTrialsTrack

Only physicians are allowed to fill the contact form. If you are a patient, please contact with your doctor. OncoTrialsTrack does not intent to replace the usual communication channels between physicians for clinical trial information exchange.

According to current regulations regarding the protection of personal data, we inform you that your personal data and the patient information you provide in this contact form will be automatically stored in our database and processed by FUNDACIÓ PRIVADA INSTITUT D'INVESTIGACIÓ ONCOLÒGICA DE VALL D'HEBRON for the purpose of management of requests that arrive through the web. The legal basis for data processing is your consent. FUNDACIÓ PRIVADA INSTITUT D'INVESTIGACIÓ ONCOLÒGICA DE VALL D'HEBRON will not transfer your data to third parties. You can exercise the rights of access, rectification, cancellation, opposition and other rights in the terms established in the current regulations in our data protection policy. Likewise, you can access our additional information about our data protection policy in the Terms of Use and Privacy Policy.

General information

Collegiate number*

Clinical Trial ID

Your name*

Your email*

Reference hospital*

Only share patient ID with patient’s consent

Patient ID

Attach medical report (pdf)

Diagnosis

Primary tumor location*

Histo-pathological subtype

ECOG*

Biopsiable metastasis?

Yes

If yes, specify:

Known molecular/genetic alterations?

Yes

If yes, specify:

Previous treatment lines

Number of previous lines

Previous immunotherapy

Yes

If yes, specify:

Previous targeted therapy?

Yes

If yes, specify:

Relevant medical condition

Hypertension

Yes

Cardiac isquemic disease or cardiac failure

Yes

Venous thrombosis and/or pulmonary embolism

Yes

Pulmonary obstructive disease

Yes

Diabetes

Yes

Renal dysfunction

Yes

Liver dysfunction

Yes

Auto-immune diseases

Yes

Other cancer

Yes

Comments

By submitting this form you agree to our Terms of Use and Privacy Policy. Information provided by you may be collected and automatically stored in our database and may be used for sending you information related to clinical resarch opportunities at FUNDACIÓ PRIVADA INSTITUT D'INVESTIGACIÓ ONCOLÒGICA DE VALL D'HEBRON.

Contact form

General information

Diagnosis

Previous treatment lines

Relevant medical condition

Comments