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	Home > Current Clinical Trials > Canine Brain Tumor Research > Apply for Brain Tumor Clinical Trials Program

Apply for Brain Tumor Clinical Trials Program

Do you have a dog you think qualifies for this program? If so, please have your veterinarian complete this form. Please note that only cases referred by professional veterinarians will be considered. All questions on this form are required.

Veterinarian Information
First Name:	Last Name:

Veterinary Clinic:

Address:


City:	State:	Zip Code:

Telephone Number:	E-mail Address:


Owner Information
First Name:	Last Name:

Telephone Number:	E-mail Address:


Dog Information
Breed:	Age:	Name:


Clinical Questions
1) Does the dog have a solitary brain mass diagnosed by CT or MRI? What is the location and approximate size of the mass?

2) What clinical signs prompted the suspicion of a brain tumor? How have these clinical signs been managed or have they changed?

3) Does the dog have any major systemic disease or other health problem that would preclude general anesthesia and intracranial surgery? If so, what are they?

4) Does the dog have a history of any previous cancers?

5) Does the dog have any current or historical evidence of lymphopenia or immune suppression (other than steroid administration to treat brain edema)?

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