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Skin Cancer Eligibility Test - Houston
1
What type of skin cancer have you been diagnosed with?
*
This field is required.
*This short questionnaire is not intended for the purpose of providing medical advice but to see if you qualify to participate in the clinical trial. Please be advised that, in submitting your responses, you will be providing personal health information (
private privacy
). Such information shall be processed for the purposes of the study only.
SCC (Squamous Cell Carcinoma)
BCC (Basal Cell Carcinoma)
Melanoma
MCC (Merkel Cell Carcinoma)
Keratoacanthoma
Lymphoma
I am not sure
I don't have a tumor
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2
What is the current condition of the tumor? Circle the most accurate answer.
*
This field is required.
I have a cancerous tumor that has been already treated
I have a cancerous tumor that hasn't been treated yet
I have a cancerous tumor that has not been completely removed
I do not have a cancerous tumor and I am looking for a preventive treatment
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3
What medical examination(s) have you undergone for this tumor?
MRI
Biopsy
PET-CT
CT
Ultrasound
No imaging test was done
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4
The location of the cancerous tumor that needs treatment.
*
This field is required.
Head/Face (cheek, ear, nose, forehead, skull, scalp etc...)
Rest of the body (Limbs - hands & feet, fingers etc...)
Internal organs (pancreas, lung, stomach, esophagus, cervix, etc...)
Oral cavity (inside lips/mouth, tongue, throat etc...)
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5
Thank you for submitting our clinical trial form!
*
This field is required.
Based on the details you have submitted, it seems that our clinical trial may help you! To go further, would you like to share with us your information and agree to our
privacy policy
so that you can be contacted by us or by someone at a participating clinical trial site?
YES
NO
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6
Please provide us with the following contact details
*
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Our specialists will get back to you as soon as possible to give you further information.
NAME
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7
Email
*
This field is required.
example@example.com
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8
Phone Number
*
This field is required.
Please enter your phone number.
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