Complete the form to refer a patient for a clinical trial at BCRC-WA.

Please complete all areas of the form. If precise dates are unknown, please give approximate dates where possible. Download and return securely via Healthlink or fax to 6500 5577.

We will respond with:

1. Patient not suitable for current clinical trial.
2. Patient possibly suitable for trial. Please send more information.
3. Patient suitable for clinical trial. Patient will be contacted for an appointment.