Patient Trials Advocate Form

This service is for support and advice in understanding and potentially accessing clinical trials. The service cannot advise on your current medical treatments - if you require medical advice please contact your Oncology team or Breast Cancer Nurse.

Other, Please specify

First Name

Last Name

Telephone number

Email address

Please confirm the NHS Trust or hospital where you receive your treatment

Please confirm the following by ticking the boxes below

I have been diagnosed with secondary breast cancer

I am interested in taking part in a clinical trial

How would you prefer to be contacted?

Before submitting this form, please

Read & Accept the Make 2nds Count Patient Trials Advocate Service Terms & Conditions. See below.

Confirm you agree to the information submitted being stored by Make 2nds Count and shared with the relevant Patient Trials Advocate (PTA) where it will also be stored on an NHS database to allow them to assist you in the search for a clinical trial.

Marketing Permissions

If you wish to receive newsletter and updates from Make 2nds Count please tick here

Patient Feedback

This is a new pilot service so your feedback is important to help us improve the service so that it can be rolled out in other areas of the UK.

If you are happy to be contacted by Make 2nds Count about the Patient Trial Advocate Service please tick here

Make 2nds Counts Clinical Trials Support Service Terms & Conditions

Service Overview

The Patient Trials Advocate (PTA) nurse will access clinical trial information from available databases.

Whilst every effort is made to ensure the most up to date information is provided to patients participating in the service, the PTA is reliant on data from third party sources, the updating of which is outside of the PTA or Make 2nds Count's control.

We do not endorse any individual trial or drug, the service is based on information and access only.

Patient Trial Advocate

The Patient Trial Advocate is a senior nurse selected and employed by the NHS. The role of PTA is funded by Make 2nds Count.

Personal Data

Makes 2nds Count will store the data collected in the referral form. We will share it with the relevant PTA where it will also be stored on an NHS database to allow them to assist patients in the search for a clinical trial.

In accordance with EU and UK’s General Data Protection Regulation, all information will be stored for a maximum of 12 months then deleted.

Make 2nds Count will not have access to any patients medical data.

In the future Make 2nds Count may contact you for feedback about the Clinical Trials Support Service. This is to help evaluate and improve the service so that it can be rolled out in other areas of the UK.

For further information please see our privacy policy https://www.make2ndscount.co.uk/privacy-policy/