Clinical Trial Navigation Questionnaire 

| Resume a previously saved form
Resume Later

In order to be able to resume this form later, please enter your email and choose a password.

Dear Patient,

Thank you for contacting Lazarex Cancer Foundation for help with identifying your clinical trial options. It is our mission to connect cancer patients to clinical trials so you can continue to stay engaged in your fight against cancer.

In order to ensure a timely turnaround for processing your request for clinical trial navigation assistance, please be sure to fill out the questionnaire completely. Upon receiving the questionnaire, our Clinical Trial Navigator will contact you.

If you have any questions, please email patientservices@lazarex.org or call 925.309.8662.

Sincerely, The Lazarex Patient Services Team
Navigation Information
Complete applications are reviewed in the order they are received.

In documents you send to us, please cross out any social security number.

A Lazarex Clinical Trial Navigator will contact the applicant to review the information received. Contact is limited to three (3) attempts. The applicant is responsible for all follow up. 

Page 2

Patient Information 
Self Spouse Family Member  Friend Healthcare Professional







5 digit zip code

Male Female Intersex













Page 3

Insurance Information 


Health History 






Yes








Yes

Yes

Yes






Molecular Testing—or “tumor genomic profiling”—is a form of testing that classifies tumors based on genetic make-up to help diagnose and treat cancer. Using a blood test or biopsy, this testing examines the DNA of cancer cells, looking for genetic mutations that have been acquired by these cells. Every tumor is unique to the patient therefore it is important to understand the unique characteristics of your type of cancer. Molecular testing does this.



Page 4

Additional Information
The following set of questions are for statistical purposes to be used only by Lazarex and will not affect whether the patient receives navigation assistance from Lazarex Cancer Foundation.







Yes No

Lazarex Cancer Foundation is committed to the principles of equitable access to services. Lazarex prohibits discrimination against any person on the basis of race, color, national origin, age, disability, sexual orientation, gender or gender expression, marital, familial, or parental status, religion, genetic information, military status, political beliefs, immigration status, or any other status protected under local, state, or federal law, in connection with its programs and activities. This policy extends to all personnel decisions, terms and conditions of employment, vendor contracts, and the provision of services. We are committed to providing an inclusive and welcoming environment for all members of our staff, volunteers, subcontractors, vendors, and patients. Lazarex Cancer Foundation is a 501 (c)(3) non-profit organization. Our tax identification number is 20-2562494.

Please submit the form digitally and Lazarex Cancer Foundation will review this information and contact the person requesting reimbursement assistance