Stomach Cancer Study
Tufts Harrington Oncollogy Program
Please use the pdf form available here If you cannot view the form then print these pages.
* Blood: 6mls of blood in an EDTA tube.
* Completed participant information form below
* Please FedEx the samples: Please call us for a FedEx account number
* Use Standard overnight
* Write “Please refrigerate upon arrival” on the box.
* Please Address to:
Dr. Elizabeth McNiel, DVM, PhD
Tufts Medical Center
75 Kneeland Street
14th Floor Room #14047
Boston, MA 02111
If samples are taken on a Friday: please refrigerate blood. Ship out on Monday.
-----------------Return Below Portion with Shipment---------------------------------------------
Affected participants: (Please include biopsy report if available)
Date of Diagnosis ___________________ Biopsy Diagnosis ______________________
Biopsy Location ______________________ Other Disease __________________________
Phone: ___________________________________ Email:_____________________
Call Name: _______________________________ Date of Birth:_______________
Registered Name: ________________________________________________
Breed:________________ AKC (or Other) Registration #: ________________________________ Please attach pedigree if available
Sex: Male, Male Neutered, Female, Female Spayed (circle one)
Please Acknowledge and Sign:
I give Dr. Elizabeth McNiel and her direct collaborators permission to use this sample for research purposes. I understand that any pedigree information or data specific to my dog will be kept confidential and any publications resulting from these studies will not include any information that will make it possible to identify a subject. In addition, I understand that I will not receive individual results regarding my dog as a result of these studies.
Signature: ________________________________ Date:_____________