BMF Consultation Form

Email address*
example@example.com
We currently conduct consults on Thursdays at 1:00 pm and 1:15 pm (Central Time). What is your preferred date and time for consult?
My case is too urgent -- need to discuss soonerOther
Requestor Information
Location*
Requested by Name*

First NameLast Name
Institution*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
Please enter a valid phone number.
Fax (US submitters: Please add the clinic fax where notifications will be sent)*
Please enter a valid phone number.
Patient Information
Name*

First NameMiddle NameLast Name
Date of birth*

MonthDayYear
Please enter patient's birthdate
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*

MaleFemale
Ethnicity*
Diagnosis/working diagnosis only*
Date of diagnosis*
Reason for consultation*
Patient Medical History
Previous medical problems (incl. syndromic features, when symptoms started, growth and development percentiles)
Presenting and current signs/symptoms (please include any syndromic features or physical exam abnormalities, including splenomegaly and/or hepatomegaly)
Past medical history
Family and social history (include number of siblings, family relationships)
Diagnostic Workup
Please enter diagnostic workup data below.
CBC (include date/s)*
Bone marrow findings, i.e., cellularity, morphology, cytogenetics, FISH, immunophenotyping (include date/s and UPLOAD THE ORIGINAL REPORT/S)*
Telomere length
Chromosome breakage
PNH
HbF
eADA
Other (Iron studies, B12, Folate, Coombs, etc.)
Genetic testing results (Include the name of the lab and date/s, gene name, and mutation information) PLEASE UPLOAD THE ORIGINAL REPORT-ALL PAGES*
Relevant imaging studies (include date/s)
Was HLA typing performed? If so, please indicate the results and if alternative donors have been identified.
Please upload relevant diagnostic documents (pdf) or images (maximum size for an individual file is 1GB; maximum number of uploads allowed is 25)

Cancelof
Treatment and Disease Evolution
Initial, previous, and current therapy (include date ranges)
Transfusion history (include the most recent transfusions)-please provide lifetime total transfusions
Please provide any additional necessary information
Should be Empty:

Requestor Information

Patient Information

Patient Medical History

Past medical history

Diagnostic Workup

Please enter diagnostic workup data below.

Treatment and Disease Evolution