The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

u8Iq5PKwtTihYr6pqQUzjzR98LsAxCv3QL2JLAyEKErhNktnjzbcQIs8F

ICARE Patient Referral Form

Returning?

A A A

Thank you for referring your patient to ICARE! Please fill in the below information and the research team will contact your patient to provide additional information about participating in ICARE.

If you have any questions or concerns, please do not hesitate to contact us.

Phone: (615) 875-2444
Email: ICARE@vumc.org

Today's Date:

* must provide value

M-D-Y

Your First Name:

Your Last Name:

Credentials:

Institution Name:

* must provide value

Institution Location:

* must provide value

Did your patient consent to having their information shared with ICARE?

* must provide value

Yes

reset

Patient's First Name:

* must provide value

Patient's Last Name:

* must provide value

Patient's Assigned Sex at Birth:

* must provide value

Female

Male

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Patient's Gender:
Old version of question. No longer asked.

Female

Male

Transgender (Male-to-Female)

Transgender (Female-to-Male)

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Patient's Date of Birth:

* must provide value

M-D-Y

Patient's Age:

View equation

Only individuals 18 years of age or older are eligible to participate in ICARE. Please try again once your patient is 18 years old.

Patient's Language Preference:

English

Spanish

Patient's Phone Number:

* must provide value

Does your patient have an email address?

* must provide value

Yes

reset

Patient's Email Address:

* must provide value

Patient's Mailing Address:

City:

State/Province:

Zip/Postal Code:

Country:

Patient's Carrier Status (if applicable):

Patient's Cancer History (if applicable):

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.