0 fb-la-form Video here For our doctors to be server you please fill out the form bellow as accurately as possible. First Name * Last Name * Email * Best Contact Phone # * Who will the patient be? Myself Mother or Father Son or Daughter Loved one or friend Age Type of Cancer How long has the patient had cancer? What General Stage Cancer? Stage 1 Stage 2 Stage 3 Stage 4 Has the patient had Chemotherapy or Radiation? Yes Chemo Yes Radiation Both None Any pre existing medical conditions? Do you have any pains? Describe your symptoms: Any prescribed medications supplements? Current occupation? Do you have life insurance Yes No Can you travel out of your state/province? Yes No How soon would you like to arrive for treatment? 24-48 hours Within 1 week Within 2 weeks Within 30 days 30 Days+ Extra Notes Click Here
