Contact – Cancer Discovery

Reach Out to Us

If you are interested in being considered for enrollment into the therapy program, please fill the form below. We will get back to you within 72 hours.

Name

Street Address

City

State

Zip Code

Country

Occupation

Phone

Date of Birth

Gender

What kind of cancer are you diagnosed with?

When was it discovered?

Please briefly describe your first treatment

Did the cancer recur?

Please briefly describe your current condition.

On a scale of 1-10, what is your current level of activity (10=very active).

What were the results of your last CT scan?

Please list your complete current medications.

If you had to travel, would you have someone to accompany you?

Have any children under the age 18?

Please briefly further describe yourself and your situation

How did you hear about us?