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CAR-T Inquiry

Interested in Chimeric Antigen Receptor Therapy (CAR-T)? Fill out the required fields and we will follow up in 1-2 business days.

CAR-T Therapy of DLBCL patients at Stanford require:

Review of all PETCT images. Scans performed outside Stanford will need to be provided as CD files for review at the time of evaluation
Lymph node biopsy speciments will require Stanford pathology review. Blocks and slides will be requested for pathology review

Patient Information

Name

Date of Birth

Address (Number, Street, City, State, Zip)

Phone

Insurance Carrier

Insurance ID#

Insurance Subscriber Information

Referring Physician

Doctor's Name

Doctor's Phone

Current Hospital or Treatment Center

Medical History

Diagnosis

History of

Autologous Transplant

Allogenic Transplant

Central Nervous System Lymphoma or Leukemia

Dates of Transplant

Date(s) of Chemotherapy Received

Dates of last 2 PET Scans

Additional Comments

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