Stomach Cancer Study
Enrollment Instructions
Tufts Harrington Oncollogy Program
Tissue donations

Please use the pdf form available here. If you cannot view the form then print these pages.

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Affected participants: (Please include biopsy report if available)

Date of Diagnosis ___________________ Biopsy Diagnosis ______________________

Biopsy Location ______________________ Other Disease __________________________

Owner Information

Name:______________________________________________________

Mailing Address:______________________________________________

Phone: ___________________________________ Email:_____________________

Dog Information

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:_____________