ACTL Immunotherapy Research Application Form

Committed to the research and development of products and technologies for targeted cellular immunotherapy for anti-tumor and other diseases

0755-8668-0658

info@immuclin.com

7th Floor, Building A, Tongfang Information Port, No. 11, Langshan Road, North District, Science and Technology Park, Nanshan District, Shenzhen

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Name :	Sex :	Age :
Cell Phone No. :	Email :
History of autoimmune disease： Yes No	Under treatment with immune inhibitor： Yes No
History of cardiovascular diseases or kidney failure： Yes No	( Currently in period of disease： Yes No )
History of allergy: Yes No
Clinical Diagnosis (including metastasis):
Pathological Diagnosis & Staging:
History of Surgery： Yes No If yes, please describe:
History of chemotherapy and/or radiotherapy： Yes No If yes, please describe:

Blood test results：
Hb:	WBC:
LYM:	MON:
Liver Function： Yes No If yes, please describe:
Kidney Function： Yes No If yes, please describe:

Infectious Disease：
HBV： Yes No	HCV： Yes No	Syphilis： Yes No	HIV： Yes No
Blood Tumor Marker :
Immunohistochemistry :
MHC Class I Molecule: Positive Negative Unknown