CAR T Therapy - Survivors/Patients/Family and Friends

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Welcome to BMT InfoNet’s CAR T Therapy community. We are gathering information to learn more about those who had or are considering CAR T Therapy. This information will help us understand more about you and what your needs are so that we can best meet them. Please complete the form or call our office at 888-597-7674.

CAR T Therapy Patient/Suvivor/Family/Friend

First Name

Last Name

Email - Home

Birth Year

Month

Day

Year

Relationship to Patient

Please select the disease from the drop down

CAR T-cell therapy

Did the Patient have CAR T Therapy *

Date of CAR-T

Month

Day

Year

Possible Date on Considering CAR T-Cell Therapy

Month

Day

Year

Patient Age at time of CAR-T

CAR-T Type

CAR-T Therapy

Other Type of CAR-T Therapy

Was CAR T part of a clinical trial

Center where CAR-T was done

Health Issues after CAR-T

Cytokine release syndrome

Neurological problems

Low White Blood Cell count

Low red blood cell count (anemia)

Other health issues after CAR-T

Please describe health after CAR T Therapy

Leave this field blank

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CAR T Therapy - Survivors/Patients/Family and Friends

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Caregiver's Role

Children and Transplant

Graft vs. Host Disease