Jordan’s Dream Fund for Clinical Trials Application - Physician Form

Patient Name

First

Last

Primary Cancer:

Primary Cancer Stage:

Clinical Trial Doctor / PI:

Direct Phone Number of Doctor / PI:

Email Address: Clinical Trial Clinic / Hospital:

Clinical Trial Address:

City

State/Province

Zip/Postal

Country

Clinical Trial Sponsor Company:

Clinical Trial NCT # (required for assistance):

Clinical Trial Name:

Is patient currently receiving financial reimbursement from clinical trial sponsor?

Yes

No

Amount:

# of payments/frequency:

Is this a reimbursement for travel expense?

Yes

No

Please select reimbursement frequency:

One time only

Every visit

If so, what type of travel?

Ground Transportation Mileage / Parking / Tolls:

(Uber, Taxi, Lyft, Rental, Train)

Lodging Air Travel:

Other (please specify):

Representative's Name

First

Last

Representative's Phone

Representative's Email

Signature

Signature

Date

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