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TRAVERA EARLY ACCESS - PLEASE READ
The following questionnaire is a comprehensive look at your current clinical circumstances. It will take about 5 minutes to complete and will help Travera determine the best next steps for your unique situation. Your information will be kept HIPAA compliant, secure, and shared only with Travera for pre-qualification. If approved, you will receive an email from our team explaining the process and answering your questions. Please keep an eye out for our email. Completing the form is no committment to testing, it simply qualifies you for the option.
I am completing this form as the patient or with the patient.
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Yes (required for participation)
No (please, return with the patient's support)
Patient's Full Name
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First Name
Last Name
Gender
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Male
Female
Date of Birth
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E-mail
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example@example.com
Phone Number
I learned about Travera's testing through:
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My Doctor
Patient/Disease Advocacy Group
Social Media Post
Friend or Family Member
Private Medical Consulting Services
Clinical Trial
What post did you see (chose all that apply)?
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Instagram Reel
TikTok Post
Facebook Post
LinkedIn Post
Post by @theoncdoc - Sanjay Juneja
Post by @thatspitfirenurseem - Em Jamieson
What group referred you? (This will help us better understand how to reach more patients like you)
What doctor referred you? (This will help us better understand how to reach more patients like you)
I am being treated IN the United States of America.
*
YES
NO
Travera is able to accept specimens from many countries but there are limitations in policy and shipping times - from what city and country would your sample be shipped?
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Begin
MY DIAGNOSIS
1. What is your primary diagnosis type? (Please select the closest option, for example if you have specific type of appendix cancer, simply select “appendix cancer”)
*
Acute Lymphoblastic Leukemia
Acute Myeloid Leukemia
Ampullary Adenocarcinoma
Anal Carcinoma
Appendix Cancer
Basal Cell Skin Cancer
Bladder Cancer
Breast Cancer
Central Nervous System Cancers
Cervical Cancer
Chronic Lymphocytic Leukemia/Small
Chronic Myeloid Leukemia
Colon Cancer
Esophageal and Esophagogastric Junction Cancers
Gastric Cancer
Gastrointestinal Stromal Tumors (GIST)
Glioblastoma
Hairy Cell Leukemia
Head and Neck Cancers
Hepatobiliary Cancers
Kidney Cancer
Lymphoma (all types)
Malignant Peritoneal Mesothelioma
Malignant Pleural Mesothelioma
Melanoma: Cutaneous
Melanoma: Uveal
Merkel Cell Carcinoma
Multiple Myeloma
Non-Small Cell Lung Cancer
Occult Primary Cancers / Unknown Primary
Ovarian Cancer/Fallopian Tube Cancer
Pancreatic Adenocarcinoma
Penile Cancer
Primary Peritoneal Cancer
Prostate Cancer
Rectal Cancer
Small Bowel Adenocarcinoma
Small Cell Lung Cancer
Sarcomas (all types)
Testicular Cancer
Thymomas and Thymic Carcinomas
Thyroid Carcinoma
Uterine Neoplasms
Vulvar Cancer
*OTHER - NOT LISTED
2. Do you currently have confirmed active disease? (primary or metastatic lesions confirmed by imaging, diagnostic laparoscopy, positive blood tests, etc.)
*
YES
NO, I am currently "NED" (No Evidence of Disease)
I recently had a positive "Minimal Residual Disease - MRD" test, but do not have any other disease visible by imaging or other methods.
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Next
MY TREATMENT HISTORY
3. When did you receive your last round of this DRUG therapy? (IV or Oral)
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I have not received any DRUGS for my cancer
It has been more than 8 weeks since my last DRUG therapy
I am currently in active DRUG treatment
I recently completed my last treatment/dose of my DRUG therapy
3a. To the best of your ability, please provide the approximate date you received your last dose of DRUG therapy? (IV or Oral)
*
Please select a month
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3b. Please let us know DRUG(S) you received as part of that therapy.
*
4. When did you receive your last dose of RADIATION therapy?
*
I have not received any RADIATION for my cancer
It has been more than 8 weeks since my last RADIATION therapy
I am currently in active RADIATION treatment
I recently completed my last round of RADIATION therapy
4a. To the best of your ability, please provide the approximate date you received your last dose of RADIATION therapy?
*
Please select a month
January
February
March
April
May
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August
September
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November
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Month
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5. Are you expecting to change your cancer drug therapy OR begin a new drug therapy in the coming weeks or months?
*
YES
NO
My doctor has recently mentioned this possibility
I don't know
6. Do you currently have fluid in your abdomen or chest?
*
YES - I have ascites (fluid in my abdomen)
YES - I have a pleural effusion (fluid in my chest)
NO - I do not have either
I don't know
6a. Has this fluid previously been proven "malignant" (has your doctor said this fluid contains cancer)?
*
YES
NO
I don't know
6b. Do you expect to have this fluid drained again in the coming weeks (this procedure is commonly called a thoracentesis or paracentesis?
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YES
NO
I currently have a catheter for regular draining of this fluid
6c. If this procedure is already scheduled - what is the approximate date of that procedure?
/
Month
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Day
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Date
7. Do you currently any of the following procedures planned (Surgery, Debulking procedure, Biopsy, Fine Needle Aspiration-FNA, or Diagnostic Laparoscopy?
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YES
NO
Expected in the coming weeks/months, but not confirmed
I don't know
7a. If this procedure is already scheduled - what is the approximate date of that procedure?
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Next
Medical Care Team
This section is optional, but if your care team has already worked with Travera in the past, the next steps in the process may be further simplified.
*TRAVERA WILL NOT CONTACT YOUR DOCTOR WITHOUT YOUR DIRECT CONSENT*
Institution primarily managing my cancer care?
Oncologist primarily managing my cancer care?
Surgeon primarily managing my cancer care?
I understand that the results of my test will be interpreted as only one element in the treatment decision-making process driven my care team. In addition, I understand that those same results may be used or published by Travera in a deidentified manner that demonstrates the test’s performance.
*
Yes (Required for participation in the EarlyAccess program)
I do not consent (Testing may still be available at normal list price)
Finish
Should be Empty: