Clone of Clone of Trial Library Patient Intake Form

Navigation Services Form

Please complete this form so a Trial Library Patient Navigator can request and transfer your medical records for a clinical trial referral. Your responses help a Patient Navigator find the right resources for you. Trial Library may use automated tools, including artificial intelligence, to help identify clinical trial matches based on your information. Feel free to skip any questions if you do not feel comfortable answering them. If you have any questions or need help with this survey, please contact the Ally Navigation Team at 844-948-2559 or email us at ally@triallibrary.com.
Name

First NameLast Name
What is your date of birth?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you able to receive mail at this address?
Phone Number
.Format: (000) 000-0000.
[OPTIONAL]
Are you the patient or are you filling out this form for the patient?
If we are unable to reach you, is there someone else we can contact on your behalf? (Optional)
Please provide their name, relationship, and contact information (phone and/or email)
Name

First NameLast Name
Relationship to Patient
Email Address
Phone Number
Format: (000) 000-0000.
Section 2: Provider Information
Physician's Name (oncologist or specialist managing your care)
Practice Name
Practice Phone Number
Practice Location

Ally Navigation Services

Patient Agreement and Intake Form
Trial Library's Ally Navigation Services help patients understand and access clinical trial options throughout their care journey. Completing this authorization and intake form is the first step in getting started and allows us to access and use relevant medical information to identify and support your experience.
By signing below, I acknowledge that I have read and understand this authorization, and I voluntarily authorize Trial Library, Inc. to use and disclose my medical information as described above.
Required
By advancing to the next page and clicking "I Agree", I confirm that I am at least 18 years old or other legal age of majority, and that I have read and agreed to Trial Library's Terms of Use and that I have read the Privacy Policy.
[OPTIONAL]
If the patient is under 18 years of age, a parent or legal guardian must sign this authorization on their behalf.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Representative Name

First NameLast Name
Relationship/Authority

Navigation Services Form