Jordan’s Dream Fund for Clinical Trials Application – Patient Form

JDF Patient

PATIENT INFORMATION

Patient's Name
Patient's Name
First
Last
Patient's Address
Patient's Address
City
State/Province
Zip/Postal
Country
Does the patient have health insurance?

REPRESENTATIVE INFORMATION (please fill out this section if person completing the application is different than the patient):

PREVIOUS CANCER TREATMENT: (check all that apply)

Chemotherapy:
Radiation:
Surgery:
Immunotherapy:
Previous Clinical Trial:

HOUSEHOLD INCOME INFORMATION

Is patient currently employed?

INCOME SOURCES

(please select all that apply

FINANCIAL ASSISTANCE REQUESTED

(Uber, Taxi, Lyft, Rental, Train)
HOW DID YOU LEARN ABOUT THIS FUND?