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e-Catalog
Membership
Portals
Members
FAQ's
Contact Us
Case Intake Form
Login
+1-800-870-6059
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e-Catalog
Membership
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Members
FAQ's
Contact Us
Case Intake Form
Login
+1-800-870-6059
Case Intake Form
Submit or update an existing support case that requires information to be evaluated by a health care provider.
Treatment Support Health Profile Update
First Name
Last Name
Email
Phone
Subject
Physician
Patient name
Indication
Anal Cancer
Arthritis
Autoimmune Disorder
Bladder Cancer
Blood Cancer
Brain Cancer
Breast Cancer
Colon Cancer
Cyst
Eczema
Infection
Inflammation
Kidney Cancer
Lung Cancer
Lyme Disease
Lymphoma
Melanoma
Metastatic Cancer
Neck Cancer
Other
Ovarian Cancer
Pancreatic Cancer
Prostate Cancer
Psoriasis
Skin Cancer
Sinus Infection
Systemic Infection
Thyroid Cancer
Testicular Cancer
Severity Index
None
Minor - 1-5 Dermo
Major - 6-10 Dermo - Soft Tissue
Early Stage - 1-2 Undiagnosed
Early Stage - 1-2 Diagnosed
Late Stage - 3-4 Undiagnosed
Late Stage - 3-4 Diagnosed
Late Stage - 3-4 Full Metastasis
Late Stage - Hospice
Initial Medical Condition
Hospitalizations / Surgeries
Concurrent Treatments
Description
Gender
Unknown
Male
Female
Age
Date of Birth
01
02
03
04
05
06
07
08
09
10
11
12
00
01
02
03
04
05
06
07
08
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49
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51
52
53
54
55
56
57
58
59
AM
PM
Height
Weight
Eye Color
Hair Color
-None-
Blonde
Red
Black
Brown
Blood Type
Unsure
A positive
A negative
B positive
B negative
O positive
O negative
AB positive
AB negative
Ethnicity
-None-
White
Hispanic or Latino
Alaska Native
American Indian
Asian
Black or African American
Middle Eastern
Native Hawaiian
Pacific Islander
Mixed Races
Languages Spoken
Select All
Unknown
English
Spanish
Mandarin
Hindi
Arabic
Portuguese
Bengali
Russian
Japenese
German
Italian
Turkish
French
Thai
Overall Health
Unknown
Excellent
Good
Poor
Lifestyle
Select All
Unknown
None
Alcohol Occassional
Alcohol Every Day
Smoking Occassional
Smoking Every Day
Exercise Occassional
Exercise Every Day
Drugs Occassional
Drugs Every Day
Immunizations
Select All
Unknown
None
Diptheria
Hepatitis B
Measles
Mumps
Pertussis
Polio
Rubella
Smallpox
Tetanus
Tuberculosis
Typhoid
Other
Diet - Nutrition Protocol
Family Medical History
Medical History
Allergies
Medications / Herbals
Existing Lab Results
Began Treatment
01
02
03
04
05
06
07
08
09
10
11
12
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
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18
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53
54
55
56
57
58
59
AM
PM
Medical Record Link
Attachment
Attach files
Each of your file(s) can be up to 20MB in size.
You can attach as many as 5 files at a time.
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