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Clinical Trial Interest Form
Please fill out the form below.
Pancreatic Cancer | NMK89P101 Trial
First Name
Middle Name
Last Name
Email
Mobile Phone
How did you find us?
Primary Care
Specialist Care
BAMF Employee
Social Media
Other
Do you have a confirmed diagnosis of pancreatic cancer?
Yes
No
Have you recently or are you currently receiving treatment for your pancreatic cancer? Please specify.
Have you had any other cancer diagnosis in the past two years?
Yes
No
Do you have any of the following illnesses?
Ongoing or active infection
Symptomatic congestive heart failure
Unstable angina pectoris (chest pain/discomfort)
Cardiac arrhythmia
Uncontrolled major seizure disorder
Chronic obstructive pulmonary disease (COPD) with low blood oxygen
Cerebrovascular accident (stroke)
Lung disease or inflammation
Spinal cord compression
Superior vena cava syndrome
Psychiatric illness
None of these apply
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