Apply for Treatment

If you have cancer and would like to know if Radiowave Therapy is an option for you, please complete the following (note that there is no cost for this initial assessment).

Patient's first name:
Patient's surname:
Patient's age:	19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
Patient's phone number:
Patient's email address:
Type of cancer:
Date of first diagnosis:
Have you had any form of treatment (tick one or more boxes)	Chemotherapy Surgery Radiotherapy Other Hormone Treatment None
If other, please specify:
Please indicate if you require continuous home oxygen?	YesNo
Please indicate if you have a pacemaker or implantable defibrillator (ICD)	YesNo
Please indicate if you are confined to a wheelchair and require a two person hoist or transfer?	YesNo
Have significant fluid collections in the lungs (pleural effusions) or abdomen (ascites)? If you are unsure please review this with your medical practitioner prior to completing this form.	YesNo
Name of person completing this form on behalf of a patient:
Home/Work phone no: (Including area code):
Mobile phone number:
Do you wish to be the primary contact person?	YesNo

Introduction

Cancer Treatment Objectives

Treatment Application Process

Application Form

Fees & Payments

Travel & Accommodation