1. Welcome to the PbR Chemotherapy Regimen Requests Portal

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* 1. Please enter today's date

Date

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* 2. Please tell us your name

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* 3. Please tell us the Organisation that you represent

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* 4. To ensure we can update you with regard to the request, please tell us your Email address

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* 5. In case we need to contact you by phone, please tell us your Telephone number (this field is not mandatory)

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* 6. Please select the Role that you have in your organisation

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* 7. Please enter the name of the new regimen that you are requesting

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* 8. Please specify the reason for your new regimen request.

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* 9. Please insert the name of the existing Regimen that you currently code to e.g. CHOP 21.

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* 10. Please provide the reason for using this regimen e.g. similar resource.

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* 11. Please specify the type of new Regimen

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* 12. Is this a clinical trial?

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* 13. If you answered "yes" to Question 12, please provide further details e.g. name, trial ARM (if applicable).

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* 14. Please let us know the specific disease being treated.

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* 15. We now need the regimen details.

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