CAR-T Inquiry Form

Interested in Chimeric Antigen Receptor Therapy (CAR-T)?

CAR-T cell therapy patients require:

Review of all PETCT images. Scans performed outside URMC will need to be provided as CD files for review at the time of evaluation.
Lymph node biopsy specimens will require URMC pathology review. Blocks and slides will be requested for pathology review.

Patient Information First Name:

Last Name:

Email:

Address:

City:

State:

Zip:

Phone:

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Referring Physician Doctor's Name:

Doctor's Phone:

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Doctor's Email:

Current Hospital or Treatment Center:

Medical History Diagnosis:

Additional Comments (please outline why patient may be eligible for CAR-T therapy):