Tissue Request Form:

* Required fields.

Contact Information

* Principal Investigator: * Email: 
* Telephone: * Fax: 
* Contact Name: * Email: 
* Telephone: Fax: 

Tissue Specimen Criteria
Anatomic Site:  * Pathology:   
Gender:   Age Range:  
 Matched Normal Tissue Metastatic Tissue

 Disease Sample Normal Sample 
 Sample Requests# of different
samples (patients)		Size
of sample 		# of different
samples (patients)		Size
of sample 
         
         
         

 *BM- Bone Marrow

    

 Price List Internal Users
 External Users Contact Us

    

 Disease SampleNormal Sample
 Slides:# of different
samples (patients)		Size
of sample		# of different
samples (patients)		Size
of sample
         
        

 Price List Internal Users
External Users Contact Us

    

Other (check all that apply):

Review of Slides
 Chart Review/Clinical Info

What anonymous clinical information do you require?                               Additional Comments and Information:

                   

** Please reference the UMass Cancer Center Tissue and Tumor Bank for publications: http://www.umassmed.edu/cancercenter/tissuebank/index.aspx**

Internal Users only –  if desired download form here.

 

Cancer Center Tissue and Tumor Bank

UMass Medical School
Lazare Research Building, Room 470 U
364 Plantation Street
Worcester, MA 01605
Phone #: 508-856-4432
Fax #: 508-856-1310