Patient Quarterly Trial Verification (QTV) 

Use this document to verify cancer clinical trial status for Lazarex patients. Have a Medical Representative (oncologist, nurse, doctor, social worker or clinical trial coordinator, etc.) complete the form.

It is the patient's responsibility to submit the completed form to Lazarex Cancer Foundation by the requested due date. 

If you have questions please contact Lazarex Cancer Foundation directly for assistance. 

To download the Quarterly Trial Verification Form, click pdfhere

Quarterly Trial Verification Form

pdfQuarterly Trial Verification Form