Travera Early Access Evaluation IO

  • SEE IF YOU QUALIFY BELOW

    OR START BY LEARNING MORE AT WWW.TRAVERA.COM

  • TRAVERA EARLY ACCESS - PLEASE READ

    The following questionnaire is a comprehensive look at your current clinical circumstances. It will take about 5 - 10 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 commitment to testing, it simply qualifies you for the option.
  • Gender*
  • Format: (000) 000-0000.
  • I learned about Travera's testing through:*
  • What post did you see (chose all that apply)?*
  • I am being treated IN the United States of America.*
  • I am interested in getting pre-qualified for or learning more about:

  • MY DIAGNOSIS

  • 1.     What is your primary diagnosis type? (Please select the closest option, for example if you have specific subtype of breast cancer, simply select “breast cancer”)*
  • 2.     Do you currently have confirmed active disease? (primary or metastatic lesions confirmed by imaging, diagnostic laparoscopy, positive blood tests, etc.)*

  • MY TREATMENT HISTORY

  • 3. When did you receive your last round of DRUG therapy? (IV or Oral)*
  • 4. When did you receive your last dose of RADIATION therapy?*
  • 5. Are you expecting to change your cancer drug therapy OR begin a new drug therapy in the coming weeks or months?*
  • 6. Tell us about your experience with IMMUNOTHERAPY?*
  • What reason were you given for not being a candidate for IMMUNOTHERAPY (check all that apply).*
  • 7. Are you currently taking any of the following drugs, that may or may not be related to your cancer diagnosis.*
  • 8. Do you currently have fluid in your abdomen or chest?*
  • Has this fluid previously been proven "malignant" (has your doctor said this fluid contains cancer)?*
  • Do you expect to have this fluid drained again in the coming weeks (this procedure is commonly called a thoracentesis or paracentesis?*
  • If this procedure is already scheduled - what is the approximate date of that procedure?
     / /
  • 9. Do you currently any of the following procedures planned (Surgery, Debulking procedure, Biopsy, Fine Needle Aspiration-FNA, or Diagnostic Laparoscopy?*
  • If this procedure is already scheduled - what is the approximate date of that procedure?
     / /

  • 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*
  • Should be Empty: