To get started please fill out and submit the following survey. Once submitted you will be redirected to a download page for the
Informed Consent Waiver.
Please complete this waiver and
Fax to Camelot Cancer Care Inc. at (918) 493-6589
First Name
Last Name
Gender
Select
Male
Female
Age
Phone
Email
Fax Number
If you have been diagnosed with cancer, please fill in the following information.
Inquirers name if different than patient
Inquirers Phone Number if different than patient
Disease
Symptoms
Cancer Type
Primary Tumor Site
Stage
Metastatic ?
Select
No
Yes
Chemotherapy already?
Select
No
Yes
Radiation ?
Select
No
Yes
Previous Treatment
Any previous surgery? Please describe procedure as best you can.
Please list any conventional therapies taken
Please list any alternative treatments
Please enter any other comments you feel would be helpful
How did you hear about us?
Indicates Response Required
Report Abuse