Appendicure Patient Data Collection Portal

Treatment History
Demographic Information
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Year of Birth
Race*

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteTwo or more racesPrefer not to sayOther
Gender*

MaleFemaleNon-binaryPrefer not to sayOtherOther
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip CodeCountry
Phone Number (Optional)

Country CodeArea CodePhone Number
Preferred Contact Method (Optional)
Email Address (Optional)
example@example.com
Diagnosis Date (Month/Year) (Optional)

MonthDayYear
Date
Primary Diagnosis*
Primary Diagnosis

Goblet Cell Adenocarcinoma (GCA)High-Grade Mucinous AdenocarcinomaSignet Ring Cell CarcinomaPseudomyxoma Peritonei (PMP)Low-grade Appendiceal Mucinous Neoplasm (LAMN)Neuroendocrine Tumor (NET/Carcinoid)
Primary Diagnosis*
Tumor Grade/Stage (if known) (Optional)
Tumor Location (Optional)

Appendix onlyPeritoneal involvementOvarian involvementOther abdominal/pelvicDistant metastasesUnknown/Not specified
Lymph Node Involvement
Primary Treatment Center(s) (Optional)
Oncologist Name(s) (Optional)
Treatments Received (select all that apply) (Optional)

Surgery (appendectomy, CRS/HIPEC, debulking)Systemic chemotherapyHIPEC (heated intraperitoneal chemotherapy)ImmunotherapyTargeted therapyClinical trial participationRadiation therapyRight hemicolectomyOther (please specify in comments)
Treatment Timeline/Summary (Optional)
Medical Documents
Pathology Reports*

PDF, JPG, PNG
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ctDNA/Liquid Biopsy Results (Optional, but if you have it we REALLY need it)

PDF, JPG, PNG
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Other Medical Records (Optional, but the MORE the BETTER :) )

PDF, JPG, PNG
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Research Participation & Future Contact
Are you interested in learning about clinical trials? (Optional)

Yes, very interestedMaybe, depending on the trialNot at this timePrefer not to answer
May we contact you about research opportunities? (Optional)

Yes, please contact meOnly for trials that closely match my diagnosisNo, don't contact me for research
If interested in trials, how far would you travel for treatment? (Optional)

Local/regional only (within 2 hours)Willing to travel within my state/regionWilling to travel nationally for the right opportunityNot applicable/not interested in trials
Additional Comments or Questions (Optional)
Optional Communications
Required consent to participate and to be contacted about optional communications related to Appendicure research and clinical opportunities. I have read and agree to the information above.*

Required consent to participate and to be contacted about optional communications related to Appendicure research and clinical opportunities. I have read and agree to the information above.
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Treatment History

Research Participation & Future Contact