Please register your interest in the

Canine Clinical Trial: Synchronisation of Immunotherapy

by submitting the form provided below

Please note: The first stage of the clinical trial has been completed. We are no longer recruiting new patients and will continue to monitor participating patients in the coming months. A second stage trial may be announced in early 2017. We are grateful for the fantastic support of the participating veterinarians and pet owners who help us immensely in understanding the relations between cancer and the immune system. We are confident this technology will change the way we approach cancer therapy.


Owner's Information

Owner's Full Name (required)

Your Email (required)

Phone number (required)

Address (required)

Surburb (required)

State (required)

Postcode (required)

Patient (Dog's) Information

Patient (Dog's) Name

Sex
MaleFemale

De-sexedEntire

Weight (Kg)

Type of Cancer

Has the cancer spread to other organs/ tissues? e.g. lungs, lymph nodes.
YesNo

If yes, provide details

Have you discussed treatment options with your vet?
YesNo

If yes, provide details

Is the dog clinically well i.e. bright & alert, eating and drinking etc?
YesNo

If no, provide details

Is the dog currently hospitalised?
YesNo

If yes, provide details

Does the patient have any of the following: advanced heart, renal, liver disease or diabetes?
YesNo

If yes, provide details

Does the patient have a history of blood clotting, blood coagulation or bleeding disorders?
YesNo

If yes, provide details

Does the patient suffer from a chronic inflammatory disease e.g. rheumatoid arthritis?
YesNo

If yes, provide details

Has your vet provided prognosis, with no treatment of less than six months life expectancy?
YesNo

If yes, provide details

Please indicate if the patient is currently receiving any medication / treatment?
YesNo

If yes, provide details