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Welcome to Clearity's Treatment Decision Support Program

To receive an initial consultation tailored to your specific situation, please:
Complete this secure and privacy-protected Treatment Decision Support Information form that includes the dates of your cancer diagnosis and treatments.
Acknowledge that your medical data will be entered into the Clearity Database.
Send us your most recent oncology progress note, your diagnostic and debulking pathology reports, most recent scan report, and tumor testing report (if you have had that testing performed).
After completing the fields below, please review this form using the navigation bar to determine if you have all the requested medical information at hand.

Once the medical information has been gathered, this form should take 15-20 minutes to complete.

All of Clearity’s services are provided free of charge.

Please Note: There is a Save and Resume option at the top of each page to leave the form and return.

*denotes required fields

Form completed by:

PatientOther

What is your relationship to the patient?

What is the cancer diagnosis?

Please identify cancer not listed:

Thank you for your interest

Thank you for reaching out to Clearity's Treatment Decision Support Program.

Currently, we only provide support to individuals who are diagnosed with ovarian, fallopian tube, or primary peritoneal cancer.

If you would like to stay in touch and receive information about Clearity and upcoming events, please fill out the information below.

First Name:

Last Name:

Date of Birth:

Email Address:

Address:

City:

State:

Zip Code:

Gender:

Race:

Please identify 'Other' Race:

Ethnicity:

Step 1: Complete the Personal Information Sections below.

Please Note: You can Save and Resume (upper right) during any part of this registration.

Patient Information

First Name:

M.I.

Last Name:

Date of Birth:

Email Address:

Phone Number:

Type:

Want to add a second phone number?

YesNo

Phone Number:

Type:

Address:

City:

State:

Zip Code:

Country

Pronouns:

Gender:

Race:

Please identify 'Other' Race:

Physician Information

Physician First Name:

Physician Last Name:

Physician Credentials:

What is the role of this physician?

Obstetrician / Gynecologist	Gynecologic Oncologist
Medical Oncologist	Surgeon

Clinic/Institution Name

City

State:

Zip Code:

Country

Patient Contact/Caregiver Information:

First Name:

Last Name:

Email Address:

Relationship:

Address:

City:

State:

Zip Code:

Country

Phone Number:

Type:

Want to add a second phone number?

YesNo

Phone Number:

Type:

Please review this form to determine if you have all the requested medical information at hand.

If you do not have all information, please click Save and Resume (upper right) to complete this form later.

Once started, this form should take 15-20 minutes to complete.

If you have questions, please contact the Treatment Decision Support team at: patientsupport@clearity.org

Diagnosis Information

Cancer Stage:

Cancer Cell Type:

Other Cancer Cell Type:

CA125 at Diagnosis:

Date of Diagnosis:

Check if date is estimated

Diagnosis Method (check all that apply):

CA125CT, PET, or MRI ScanBiopsyParacentesis/ThoracentesisSurgeryOther

Other Diagnosis Method:

Date of Biopsy:

Check if date is estimated

Date of Paracentesis/Thoracentesis:

Check if date is estimated

Date of Surgery:

Check if date is estimated

Description of Surgery (select all that apply):

Bilateral Salpingo-OophorectomyDebulkingDiagnostic LaparoscopyExploratory LaparotomyHysterectomyLymph Node DissectionOmentectomyTumor ResectionOther

Other (please specify):

Did you have surgery after diagnosis?

YesNo

Date of Surgery:

Check if date is estimated

Description of Surgery (select all that apply):

Bilateral Salpingo-OophorectomyDebulkingDiagnostic LaparoscopyExploratory LaparotomyHysterectomyLymph Node DissectionOmentectomyTumor ResectionOther

Other (please specify):

Test Results

Did you have a blood test performed for inherited mutations in cancer risk genes (e.g., BRCA)?

YesNo

What was the result?

Did you have your tumor tested for biomarkers like HRD and genetic mutations?

YesNo

Please specify the name of the test:

FoundationOne	Caris MI Profile
Tempus	MSK Impact
UCSF500	Myriad MyChoice HRD
Strata	MD Anderson
Other	I am unsure/Do not know

Please specify:

Treatment Information

Have you had cancer treatment (e.g., chemotherapy, targeted therapy (e.g., PARP inhibitor), hormone therapy, or immunotherapy)?

YesNo

Drug Received:

Start typing to reveal drugs

When did you receive this treatment?

Start Date:

Check if date is estimated

End Date:

Check if date is estimated

Did you get this treatment in a clinical trial?

YesNo

NCT# (if known):

Did you receive maintenance after this treatment?

YesNo

Drug Received:

Start typing to reveal drugs

When did you receive this treatment?

Start Date:

Check if date is estimated

End Date:

Check if date is estimated

Did you get this treatment in a clinical trial?

YesNo

NCT# (if known):

Did you have a recurrence (or did the cancer grow)?

YesNo

Date of Recurrence/Progression:

Check if date is estimated

Did you have another surgery?

YesNo

Date of Surgery:

Check if date is estimated

Description of Surgery (select all that apply):

Bilateral Salpingo-OophorectomyDebulkingDiagnostic LaparoscopyExploratory LaparotomyHysterectomyLymph Node DissectionOmentectomyTumor ResectionOther

Other (please specify):

Did you have another treatment?

YesNo

Drug Received:

Start typing to reveal drugs

When did you receive this treatment?

Start Date:

Check if date is estimated

End Date:

Check if date is estimated

Did you get this treatment in a clinical trial?

YesNo

NCT# (if known):

Did you receive maintenance after this treatment?

YesNo

Drug Received:

Start typing to reveal drugs

When did you receive this treatment?

Start Date:

Check if date is estimated

End Date:

Check if date is estimated

Did you get this treatment in a clinical trial?

YesNo

NCT# (if known):

Did you have another recurrence (or did the cancer grow)?

YesNo

Date of Recurrence/Progression:

Check if date is estimated

Check to add another treatment or surgery

Did you have another surgery?

YesNo

Date of Surgery:

Check if date is estimated

Description of Surgery (select all that apply):

Bilateral Salpingo-OophorectomyDebulkingDiagnostic LaparoscopyExploratory LaparotomyHysterectomyLymph Node DissectionOmentectomyTumor ResectionOther

Other (please specify):

Did you have another treatment?

YesNo

Drug Received:

Start typing to reveal drugs

When did you receive this treatment?

Start Date:

Check if date is estimated

End Date:

Check if date is estimated

Did you get this treatment in a clinical trial?

YesNo

NCT# (if known):

Did you receive maintenance after this treatment?

YesNo

Drug Received:

Start typing to reveal drugs

When did you receive this treatment?

Start Date:

Check if date is estimated

End Date:

Check if date is estimated

Did you get this treatment in a clinical trial?

YesNo

NCT# (if known):

Did you have another recurrence (or did the cancer grow)?

YesNo

Date of Recurrence/Progression:

Check if date is estimated

Check to add another treatment or surgery

Did you have another surgery?

YesNo

Date of Surgery:

Check if date is estimated

Description of Surgery (select all that apply):

Bilateral Salpingo-OophorectomyDebulkingDiagnostic LaparoscopyExploratory LaparotomyHysterectomyLymph Node DissectionOmentectomyTumor ResectionOther

Other (please specify):

Did you have another treatment?

YesNo

Drug Received:

Start typing to reveal drugs

When did you receive this treatment?

Start Date:

Check if date is estimated

End Date:

Check if date is estimated

Did you get this treatment in a clinical trial?

YesNo

NCT# (if known):

Did you receive maintenance after this treatment?

YesNo

Drug Received:

Start typing to reveal drugs

When did you receive this treatment?

Start Date:

Check if date is estimated

End Date:

Check if date is estimated

Did you get this treatment in a clinical trial?

YesNo

NCT# (if known):

Did you have another recurrence (or did the cancer grow)?

YesNo

Date of Recurrence/Progression:

Check if date is estimated

Check to add another treatment or surgery

Did you have another surgery?

YesNo

Date of Surgery:

Check if date is estimated

Description of Surgery (select all that apply):

Bilateral Salpingo-OophorectomyDebulkingDiagnostic LaparoscopyExploratory LaparotomyHysterectomyLymph Node DissectionOmentectomyTumor ResectionOther

Other (please specify):

Did you have another treatment?

YesNo

Drug Received:

Start typing to reveal drugs

When did you receive this treatment?

Start Date:

Check if date is estimated

End Date:

Check if date is estimated

Did you get this treatment in a clinical trial?

YesNo

NCT# (if known):

Did you receive maintenance after this treatment?

YesNo

Drug Received:

Start typing to reveal drugs

When did you receive this treatment?

Start Date:

Check if date is estimated

End Date:

Check if date is estimated

Did you get this treatment in a clinical trial?

YesNo

NCT# (if known):

Did you have another recurrence (or did the cancer grow)?

YesNo

Date of Recurrence/Progression:

Check if date is estimated

Check to add another treatment or surgery

Did you have another surgery?

YesNo

Date of Surgery:

Check if date is estimated

Description of Surgery (select all that apply):

Bilateral Salpingo-OophorectomyDebulkingDiagnostic LaparoscopyExploratory LaparotomyHysterectomyLymph Node DissectionOmentectomyTumor ResectionOther

Other (please specify):

Did you have another treatment?

YesNo

Drug Received:

Start typing to reveal drugs

When did you receive this treatment?

Start Date:

Check if date is estimated

End Date:

Check if date is estimated

Did you get this treatment in a clinical trial?

YesNo

NCT# (if known):

Did you receive maintenance after this treatment?

YesNo

Drug Received:

Start typing to reveal drugs

When did you receive this treatment?

Start Date:

Check if date is estimated

End Date:

Check if date is estimated

Did you get this treatment in a clinical trial?

YesNo

NCT# (if known):

Did you have another recurrence (or did the cancer grow)?

YesNo

Date of Recurrence/Progression:

Check if date is estimated

Check to add another treatment or surgery

Did you have another surgery?

YesNo

Date of Surgery:

Check if date is estimated

Description of Surgery (select all that apply):

Bilateral Salpingo-OophorectomyDebulkingDiagnostic LaparoscopyExploratory LaparotomyHysterectomyLymph Node DissectionOmentectomyTumor ResectionOther

Other (please specify):

Did you have another treatment?

YesNo

Drug Received:

Start typing to reveal drugs

When did you receive this treatment?

Start Date:

Check if date is estimated

End Date:

Check if date is estimated

Did you get this treatment in a clinical trial?

YesNo

NCT# (if known):

Did you receive maintenance after this treatment?

YesNo

Drug Received:

Start typing to reveal drugs

When did you receive this treatment?

Start Date:

Check if date is estimated

End Date:

Check if date is estimated

Did you get this treatment in a clinical trial?

YesNo

NCT# (if known):

Did you have another recurrence (or did the cancer grow)?

YesNo

Date of Recurrence/Progression:

Check if date is estimated

Check to add another treatment or surgery

Did you have another surgery?

YesNo

Date of Surgery:

Check if date is estimated

Description of Surgery (select all that apply):

Bilateral Salpingo-OophorectomyDebulkingDiagnostic LaparoscopyExploratory LaparotomyHysterectomyLymph Node DissectionOmentectomyTumor ResectionOther

Other (please specify):

Did you have another treatment?

YesNo

Drug Received:

Start typing to reveal drugs

When did you receive this treatment?

Start Date:

Check if date is estimated

End Date:

Check if date is estimated

Did you get this treatment in a clinical trial?

YesNo

NCT# (if known):

Did you receive maintenance after this treatment?

YesNo

Drug Received:

Start typing to reveal drugs

When did you receive this treatment?

Start Date:

Check if date is estimated

End Date:

Check if date is estimated

Did you get this treatment in a clinical trial?

YesNo

NCT# (if known):

Did you have another recurrence (or did the cancer grow)?

YesNo

Date of Recurrence/Progression:

Check if date is estimated

Check to add another treatment or surgery

Did you have another surgery?

YesNo

Date of Surgery:

Check if date is estimated

Description of Surgery (select all that apply):

Bilateral Salpingo-OophorectomyDebulkingDiagnostic LaparoscopyExploratory LaparotomyHysterectomyLymph Node DissectionOmentectomyTumor ResectionOther

Other (please specify):

Did you have another treatment?

YesNo

Drug Received:

Start typing to reveal drugs

When did you receive this treatment?

Start Date:

Check if date is estimated

End Date:

Check if date is estimated

Did you get this treatment in a clinical trial?

YesNo

NCT# (if known):

Did you receive maintenance after this treatment?

YesNo

Drug Received:

Start typing to reveal drugs

When did you receive this treatment?

Start Date:

Check if date is estimated

End Date:

Check if date is estimated

Did you get this treatment in a clinical trial?

YesNo

NCT# (if known):

Did you have another recurrence (or did the cancer grow)?

YesNo

Date of Recurrence/Progression:

Check if date is estimated

Check to add another treatment or surgery

Did you have another surgery?

YesNo

Date of Surgery:

Check if date is estimated

Description of Surgery (select all that apply):

Bilateral Salpingo-OophorectomyDebulkingDiagnostic LaparoscopyExploratory LaparotomyHysterectomyLymph Node DissectionOmentectomyTumor ResectionOther

Other (please specify):

Did you have another treatment?

YesNo

Drug Received:

Start typing to reveal drugs

When did you receive this treatment?

Start Date:

Check if date is estimated

End Date:

Check if date is estimated

Did you get this treatment in a clinical trial?

YesNo

NCT# (if known):

Did you receive maintenance after this treatment?

YesNo

Drug Received:

Start typing to reveal drugs

When did you receive this treatment?

Start Date:

Check if date is estimated

End Date:

Check if date is estimated

Did you get this treatment in a clinical trial?

YesNo

NCT# (if known):

Did you have another recurrence (or did the cancer grow)?

YesNo

Date of Recurrence/Progression:

Check if date is estimated

Describe any additional treatments or surgeries here:

Additional Treatment and/or Comments Related to Cancer History:

Additional Questions

Treatment Information Request:

Front-line treatment with or without maintenance	Treatment for recurrence
Maintenance treatment after recurrence	Clinical trial options

How did you hear about Clearity?

Other (please specify):

I am interested in receiving communications from Clearity pertaining to ovarian cancer news/information and Clearity events:

YesNo

I am interested in receiving information from Clearity about the Steps Through OC program that provides psychosocial/emotional support for ovarian cancer survivors and active caregivers (USA only).

YesNo

Informed Consent for Clinical and Tumor Molecular Profiling Data

Purpose

In its Treatment Education Program, Clearity provides information about standard treatment options for your clinical situation as well as the latest promising results from drugs in clinical development. A member of the Clearity scientific team will review your clinical and tumor testing information with you and help you find clinical trials for which you may be eligible, if/when appropriate.

Clearity does not provide medical advice about which treatments you should receive. Instead, our staff explain tumor-testing results and standard treatment options for your situation as well as provide potential questions, and other information, that you can discuss with your physician.

Clinical Information and Test Results

You have provided us with your clinical information (e.g., clinical history) and will be having the results from the testing of your tumor (or blood) sample sent to us. That testing was performed to find out if your cancer has certain molecular biomarkers. The biomarkers include chemical materials, such as proteins and RNA, which may cause cancer cells to grow out of control. The biomarkers may also include changes in your DNA, called mutations. Biomarker test results may help your doctor make decisions about the best treatment options for your ovarian cancer.

Storage of Your Information in the Clearity Database

To help with your educational discussions with Clearity staff, we will enter the clinical information that you provide to us from your medical records (e.g., surgeries, chemotherapy treatments) into The Clearity Foundation Database. To enable our search of clinical trials that match the biomarkers in your tumor, we also enter the chemical and genetic information about your tumor samples into the Database. Your personal information (name, address, medical record number, etc.) and clinical information will be kept confidential in a privacy-protected, securely encrypted place.

The Clearity Foundation keeps your clinical information and tumor molecular profiling results confidential and fully obeys the Health Insurance Portability and Accountability Act (HIPAA). Your information will only be released as directed by you, which would include the healthcare provider (s) or his or her designee, as directed by you (or a person legally authorized to act on your behalf) in writing, or as required by federal and state laws.

Possible Risks

The Clearity Foundation takes all reasonable steps to protect confidentiality, but confidentiality cannot be guaranteed.

Possible Benefits

Understanding standard of care options, and knowing the molecular profile of your tumor may help you and your doctor make more informed choices about your cancer treatment. However, there is no guaranteed benefit to you from the educational and clinical trial information provided by Clearity staff.

Consent

By checking this box, I agree to the following:

I have read and have access to a copy of this form.
I understand the information provided and my questions have been answered.
I agree to have my clinical information and tumor testing results incorporated into the Clearity Foundation Database.

Full Name

Name of Authorized Patient Representative

Date:

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