Preliminary Search Request Form

Please check one:
This is the first request.
Patient has had a previous request. No change in information.
Update or add information to previous request.

Patient Information:

Ethnic Background Information:

The information below will help in matching donors and patients. (Please check one)

Hispanic or Latino
Not Hispanic or Latino

* With which of the following group(s) does the patient identify? (Check all that apply):

Since certain HLA types may be more common in each race group, the information may help in selecting donors for further HLA testing at later stages of the search process.

If the patient's parents are from more than one of the following groups, check all that apply.
White
Black or African American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaska Native
Unknown
Patient declines to provide race

HLA Typing:

* Primary Diagnosis:

* Current Disease and Status:
Indicate if disease status is induction therapy, induction failure, remissions, relapse or chronic, accelerated or blast phase.

Patient Information:

Ethnic Background Information:

* With which of the following group(s) does the patient identify? (Check all that apply):

HLA Typing:

* Primary Diagnosis:

Referring Physician Information:

BMT Coordinator/Contact Person: