REFERRAL FORM
ONCOLOGY
PATIENT INFORMATION
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
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Gender
*
Male
Female
Please select
Gender?
Male
Female
UMRN or N/A:
*
Mobile Number or N/A
*
Home Number or N/A
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Does the patient require an interpreter?
*
No
Yes (specify language below)
Language
If yes, please provide details of a family member who can speak English below
Rows
First Name
Last Name
Phone
Details
DIAGNOSIS INFORMATION
Initial Diagnosis
*
Subtype or N/A
*
Date of Initial Diagnosis
*
-
Day
-
Month
Year
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Upload Histology
*
Browse Files
Cancel
of
Known Mutations or N/A
*
Attach Molecular Report
Browse Files
Cancel
of
Past History of Other Cancers?
*
Yes
No
Please select
Past History of Other Cancers?
Yes
No
If yes, Confirm Cancer, Dates and Treatment
PREVIOUS TREATMENT INFORMATION
Most Recent Anti-Cancer Treatment
*
Rows
Treatment or Combination
Start Date dd/mm/yyyy
End Date dd/mm/yyyy
Best Response
Indication
Number of Cycles
1
Complete Response
Partial Response
Stable Disease
Progression
Adjuvant
Neo-Adjuvant
Locally Advance
Metastatic
Palliative
2
Complete Response
Partial Response
Stable Disease
Progression
Adjuvant
Neo-Adjuvant
Locally Advance
Metastatic
Palliative
3
Complete Response
Partial Response
Stable Disease
Progression
Adjuvant
Neo-Adjuvant
Locally Advance
Metastatic
Palliative
4
Complete Response
Partial Response
Stable Disease
Progression
Adjuvant
Neo-Adjuvant
Locally Advance
Metastatic
Palliative
5
Complete Response
Partial Response
Stable Disease
Progression
Adjuvant
Neo-Adjuvant
Locally Advance
Metastatic
Palliative
6
Complete Response
Partial Response
Stable Disease
Progression
Adjuvant
Neo-Adjuvant
Locally Advance
Metastatic
Palliative
7
Complete Response
Partial Response
Stable Disease
Progression
Adjuvant
Neo-Adjuvant
Locally Advance
Metastatic
Palliative
8
Complete Response
Partial Response
Stable Disease
Progression
Adjuvant
Neo-Adjuvant
Locally Advance
Metastatic
Palliative
9
Complete Response
Partial Response
Stable Disease
Progression
Adjuvant
Neo-Adjuvant
Locally Advance
Metastatic
Palliative
10
Complete Response
Partial Response
Stable Disease
Progression
Adjuvant
Neo-Adjuvant
Locally Advance
Metastatic
Palliative
List of Other Prior Therapies
*
Previously Radiotherapy or N/A
Rows
Site
Start Date dd/mm/yyyy
Stop Date dd/mm/yyyy
Total Dose (Grays)
Type
1
3D Conformal
IMRT
VMAT
IGRT
SRS
Brachytherapy
SXRT
IORT
2
3D Conformal
IMRT
VMAT
IGRT
SRS
Brachytherapy
SXRT
IORT
3
3D Conformal
IMRT
VMAT
IGRT
SRS
Brachytherapy
SXRT
IORT
CURRENT STATUS
ECOG Performance Status
List Comorbidities
*
Past History of Autoimmune Disease?
*
Yes
No
Please select
Past History of Autoimmune Disease?
*
Yes
No
If yes, specify
List Current Medications or Specify None
*
Any Recent Systemic Steroid Therapy?
*
Yes
No
If Yes, specify
Rows
Name
Dose
Date Started
Date Last Dose
Indication
1
Other Concomitant Medications Taken in Last 30 Days
*
Rows
Name
Indication
Start Date YYYY/MM/DD
End DateYYYY/MM/DD
1
Adjuvant
Neo-Adjuvant
Locally Advance
Metastatic
Palliative
2
Adjuvant
Neo-Adjuvant
Locally Advance
Metastatic
Palliative
3
Adjuvant
Neo-Adjuvant
Locally Advance
Metastatic
Palliative
4
Adjuvant
Neo-Adjuvant
Locally Advance
Metastatic
Palliative
5
Adjuvant
Neo-Adjuvant
Locally Advance
Metastatic
Palliative
6
Adjuvant
Neo-Adjuvant
Locally Advance
Metastatic
Palliative
7
Adjuvant
Neo-Adjuvant
Locally Advance
Metastatic
Palliative
8
Adjuvant
Neo-Adjuvant
Locally Advance
Metastatic
Palliative
9
Adjuvant
Neo-Adjuvant
Locally Advance
Metastatic
Palliative
10
Adjuvant
Neo-Adjuvant
Locally Advance
Metastatic
Palliative
Any Recent Systemic Steroid Therapy?
Yes
No
Please select
Latest Laboratory Results or upload results
*
Rows
Laboratory
Date of Test
1
PathWest
Australian Clinical Labs
Western Diagnostics
CliniPath
Other, please upload results
2
PathWest
Australian Clinical Labs
Western Diagnostics
CliniPath
Other, please upload results
Upload laboratory Results
Browse Files
Cancel
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Latest Imaging Results or upload results
*
Rows
Imaging Vendor
Date of Test
Type of Scan
1
Public
PRC
SKG
Invision
Other
Insight Clinical Imaging
Oceanic Molecular
Other, please upload results
2
Public
PRC
SKG
Invision
Other
Insight Clinical Imaging
Oceanic Molecular
Other, please upload results
3
Public
PRC
SKG
Invision
Other
Insight Clinical Imaging
Oceanic Molecular
Other, please upload results
Upload Imaging Results
Browse Files
Cancel
of
Does the patient have adequate venous access?
*
Yes
No
Does the patient have a port or PICC in situ for IV access?
*
No
Yes, Port-o-Cath
Yes, PICC line
What is the patient's COVID-19 Vaccination status?
Vaccinated
Unvaccinated
Unknown
Additional Information
To ensure eligibility for clinical trials, a comprehensive medical and treatment history is required. Please ensure all relevant documentation is provided. If further clarification is needed, we may contact your practice’s clinical or administrative team. Please include contact details for a person we can liaise with regarding the patient’s medical records.
Contact Name
*
Contact Email
*
example@example.com
Contact Phone Number
*
REFERRING PHYSICIAN
Brief Referral Narrative
*
Referring hospital / practice?
*
Name
*
First Name
Last Name
Provider Number
*
Email
*
example@example.com
Mobile Number
*
Responsible Consultant
*
First Name
Last Name
Signature of referring Physician
*
Date
*
-
Day
-
Month
Year
Date Picker Icon
Where did you hear about Linear?
*
Linear Clinical Research website
Cancer Trials WA website
Colleague recommendation
Social media (LinkedIn, Instagram, Facebook etc.)
Search engine
Other
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