Patient Intake Form — Cancer and Hope

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Registration Received!

Thank you for registering. A Cancer and Hope coordinator will contact you within 24–48 hours via your preferred contact method.

Maraming salamat sa inyong tiwala. Makikipag-ugnayan sa inyo ang aming coordinator sa loob ng 24–48 na oras.

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1. About the Patient

First Name (required)

Last Name (required)

Age (required)

Sex at Birth (required)

City / Province (required)

2. Medical Information

Type of Cancer (required)

Cancer Stage (if known)

It's okay if you don't know your stage yet. Our specialists can help determine this from your medical records.

Approximate Date of Diagnosis

Treatments Received So Far (select all that apply)

Surgery Chemotherapy Radiation Therapy Targeted Therapy Immunotherapy Hormonal Therapy No treatment yet

Current Medications or Ongoing Treatment

Brief Medical Summary (optional but helpful)

You may also bring or email your pathology report, imaging scans, or doctor's notes — these will help the specialist greatly.

Your Questions for the Doctor

3. Contact Information

We will use this information only to contact you about your registration. We will never share it with third parties.

Mobile Number (required)

Viber / WhatsApp Number (if different)

Email Address (optional)

Preferred Contact Method (required)

Phone Call Viber Message WhatsApp Email

Best Time to Contact You

Preferred Communication Language

4. Consent & Acknowledgment

🔒 Your information is treated with complete confidentiality. We collect only what is needed to connect you with a specialist. We will never sell or share your data with advertising companies or unauthorised third parties. You may request deletion of your information at any time by contacting us.

I consent to being contacted by Cancer and Hope coordinators via my preferred method. (required) I understand that my medical summary may be shared with partner Chinese oncologists for the purpose of recommending treatment. (required) I understand that Cancer and Hope is a coordination and education service, not a medical provider, and that information received is not a substitute for professional medical advice.

A coordinator will contact you within 24–48 hours after receiving your form.

Makikipag-ugnayan sa inyo ang coordinator sa loob ng 24–48 na oras.