Blood Cancer UK Clinical Trials Navigation Service webform

Clinical Trials Navigation Service webform

Our Clinical Trials Nurses are available Monday to Friday (except Bank holidays). If you'd like to get in touch, please complete the form below.

At Blood Cancer UK our Clinical Trials Navigation Service provides personalised guidance to anyone affected by blood cancer about clinical trials. To help us achieve this goal, we ask for optional diversity information and health-related questions. We take your privacy seriously and comply with GDPR regulations to protect your personal information. Please read our Privacy Policy for more information.

Fields marked with an asterisk are required.

Your first name *

Your last name *

Your email address *

Your phone

You will be invited to book a call after you submit this form. If you would prefer to receive email support only, please tick this box

This will involve answering questions over email to gather more information(if you choose email contact you have the option of changing to telephone/video call at any time).

Your postcode

How did you find the Clinical Trials Navigation Service? *

Who is this referral for? *

Myself
My family member
My friend
My patient (Healthcare professional referral)
Other (please tell us in the additional information box below)

If you are a healthcare professional referring a patient, please enter your own contact details above, then enter your patient's details below.

What type of blood cancer? *

We've tried to cover everything but if your blood cancer is not listed please select 'Other not listed' and let us know in the additional information box

How would you describe your (or their) current condition? *

If you would like to share any additional information about your (or their) diagnosis, medical history, previous treatment(s) you might have had please do so here. If your (or their) blood cancer is not listed please add it here.

For e.g. What is the plan from your (or their) medical team at present? Anything further you'd like to share?

How can the trial navigation service help? *

At which hospital do you (or they) receive care? *

Have clinical trials been discussed by the treating team? *

Please choose the option that best describes your ethnic group or background: *

If you are a healthcare professional, please submit the ethnicity of the person affected by blood cancer.

Please accept our terms of service *

We will store your personal information including any medical details you share with us. Your data is stored securely in line with the Data Protection Act 2018. Your personal information will not be shared with any third parties without your explicit consent; however we will input information pertaining to your blood cancer into various databases to enable us to perform a trial search. This data is not stored in the databases we use and is not identifiable. Whilst every effort is made to ensure that the most up-to-date information is provided to service users we can be limited by databases that are not frequently updated and are outside of our control. For further information please see our Privacy Policy. You have the right to request to be removed from our records at any time. You may periodically receive surveys intended to gather feedback on the service; participation is entirely optional.

Security check *

Once you 'Click to submit' below, you will be able to book an appointment to speak to one of our nurses.

If you've selected email contact only, you will receive an email from one of our nurses.

I've just been told I have blood cancer

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Clinical Trials Navigation Service webform

Once you 'Click to submit' below, you will be able to book an appointment to speak to one of our nurses.