Thank you for your interest in our service.In order for our medical team to evaluate whether or not you are eligible for treatment and recommend a relevant medical program and treatment for you, please fill in the form below to the best of your ability or with the help of your physician. Name* First Last Date of Birth* CountryPlease select oneAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweEmail* PhoneHeightUnitCMINCHESWeightUnitKGPOUNDHistory and DiagnosisWhat is your Primary diagnosis?* When were you first diagnosed? MM DD YYYY If you don't remember the specific date, just fill in the year of diagnoses with or without month.How was the disease diagnosed? Surgical Biopsy Fine Needle Aspiration Resection Please describe the progression of your condition from early symptoms until now. Have you taken surgeries, chemotherapy or radiation therapy? If yes, what’s the program? (Medication, dosage and period, etc.) Does anyone in your family have medical history relevant to your condition? SymptomsPlease list your main complaint currently and all your current general condition: (appetite/ performance of daily activities/ fatigue/ vision/breathing/ chest pain/ headache/ dizziness/jaundice/ascites/eating problem etc.) Has the disease spread to other organs? If yes, please specify where and the date it was discovered. MedicationsPlease list any medications that you are currently taking with dosage and effectiveness and / or side effects What is the date of the last treatment? When is the next treatment scheduled? Please list the diagnostic exams you have had along with date, results and if images are available on request. Any medical records that you can send us will be helpful for your medical evaluation.Be sure to include with the forms the following information:Typed pathology reportsTyped surgical reports, MRI reportsTyped medical and treatment history summary Typed laboratory reportsTyped radiology (x-ray, CT scans, ultrasound, bone scan prepared by your physicianMost recent lab values (CBC w/Diff & chemistries, i.e. BUN, Cre. Ca+)Pathological paraffin tissue section(Please note: MRI scan is recommended within last 30 days)Medical records or recent oncological evaluation from your oncologist FileFileFileFileFileHypertensionNoYesHeart diseaseNoYesDiabetesNoYesCVA/ StrokeNoYesLung diseaseNoYesLiver diseaseNoYesKidney diseaseNoYesFracture or breakNoYesCancer or tumorNoYesInflammation or infectionNoYesOthersNoYesPlease explain, give exact diagnosis and date of diagnosis.Other informationIs there a caregiver who can provide you with care and assistance during your stay at the hospital if necessary?NoYesDo you smoke?NoYesAre you currently using or ever used drugs or alcohol?NoYesDo you have sleep apnea, chronic obstructive pulmonary disease or other condition that doesn't allow for general anesthesia?NoYesIf you answered yes to any of the above, please clarify. Validation This is to prevent spam.