Private Patient Evaluation IntakeFull Name *Email Address *PhoneCountry of Residence *Preferred LanguageHave you been diagnosed with...?CancerAutoimmune DiseaseLong COVIDNeurological ConditionOtherCancer Type (if applicable)Diagnosis StageDate of DiagnosisAdditional Health ConditionsPrior TreatmentsChemotherapyRadiationSurgeryImmunotherapyHolistic/Alternative TherapyNo Prior TreatmentOtherUpload Medical RecordsAll uploads are encrypted in transmission and reviewed privately by our medical board.Drag and Drop (or) Choose FilesConsent & Submission *I understand that this form is for evaluation purposes only and does not constitute a medical diagnosis or guarantee of treatment. I consent to secure review by the clinical intake team.Consent & Submit
