Request A Mentor

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Request a Mentor

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Your Role: *

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First Name *

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Last Name *

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Email *

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Address 1 *

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Address 2

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City *

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State *

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Country *

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Zip *

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Phone *

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Please contact me by: *

Phone

Email

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Primary Language *

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Please state the name of the person who referred you to DDF, if any.

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Patient Information

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First Name *

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Last Name *

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Email *

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Address 1 *

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Address 2

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City *

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State *

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Country *

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Zip *

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Phone *

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Gender *

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Age:

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Diagnosis and Staging Information

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Diagnosis *

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Date of diagnosis

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Stage *

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Has the patient had chemotherapy? Check all that apply. *

No

Yes, 5-FU (flourouracil)

Yes, Capecitabine (Xeloda)

Yes, Carboplatin

Yes, Cisplatin

Yes, Docetaxel (Taxotere)

Yes, Epirubicin (Ellence)

Yes, Oxaliplatin (Eloxatin

Yes, Paclitaxel (Taxol)

Yes, Other

Yes, Unknown

Yes, Irinotecan (Camptosar)

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Has the patient had radiation? *

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Has the patient had surgery? Check all that apply. *

No

Yes, partial gastrectomy

Yes, total gastrectomy

Yes, other

No, but planned or scheduled

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Has the patient had genetic and/or biomarker testing? *

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If yes, is the patient positive for any biomarkers? Check all that apply.

ERBB2/HER2 Amplification

MSI

PD-L1

EBV

MET Amplification

EGFR Amplification

ERBB2 Mutation

FGFR2 Amplification

KRAS Amplification

CDK6 or CCND1 Amplification

ATM Mutation or BRCA1/2

None

Unknown

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Has the patient been on a clinical trial? *

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If yes, please list:

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Treating physician/center

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Information Requested

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What do you have questions about?

Getting a Second Opinion

Clinical Trials

Support Resources

Palliative Care

Side Effect Management

Other, Please list below

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Other Questions

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