This form is intended for referring specialists. We ask you to complete this form as completely as possible and to include all relevant documentation. After sending this form, our planning department will process the data and the patient will be discussed at the national TIL melanoma MDO. If you have any questions, please call the following telephone number: 020 512 9111 Fields with a * are required.

Change language	Nederlands English
Refer patient to	Select... TIL therapie melanoom

Referrer data
Referrer name	*
Name institution	*
Specialism
Email	* Invalid email address
Phone number	*
Contact person for additional data

Patient data
Last name	*
Initials	*
Gender	Select... Male Female *
Date of birth	*  mm-dd-yyyy Invalid date
Address	*
House nr. /  Addition	*
Postcode
City
Phone number	*
Email	Invalid email address
SSN	* Incorrect BSN
Already been in the AVL?

Indication
Disease progression after or during anti-PD-1 therapy           (adjuvant stage III or for metastatic melanoma)
Disease progression after or during ipilimumab/nivolumab
Diagnosis and history
Diagnosis/suspicion
Oncological history
None-oncological history
Diagnostics
Metastasis larger than 2cm (Please attach print screen)	Select... Yes No *
	Only jpg en png files are allowed.
Image formation	mm-dd-yyyy Invalid date
BRAF V600 mutation	Select... Yes No *
Qualification
Age between 18 and 75	Select... Yes No *
WHO PS 0 - 1	Select... Yes No *
Evalueerbare ziekte na resectie laesie t.b.v. TIL productie (niet noodzakelijker wijs meetbaar volgens RECIST1.1)	Select... Yes No *
LDH Concentratie verhoogd	Select... Yes No *
Ejectiefractie > 40% en klinisch goede LV functie	Select... Yes No Unknown *
Baseline saturatie ≥ 92% bij kamerlucht	Select... Yes No *
HIV/HepB/HepC infectie	Select... Yes No Unknown *
CNS metastasen	Select... Yes No *
Indien ja, bestraald?	Select... Yes No *
Neurologische afwijkingen	Select... Yes No *
Andere significante comorbiditeit	Select... Yes No *
Remarks

Appointment confirmation
Send confirmation to	Patient Referrer

Refferal materials
Reports   (Imaging, Scopy, Pathology and/or OR)	Only pdf- en Word files are allowed.
	Only pdf- en Word files are allowed.
	Only pdf- en Word files are allowed.
	Only pdf- en Word files are allowed.
	Only pdf- en Word files are allowed.
	Only pdf- en Word files are allowed.
Type the code for verification	* Invalid code