Register for Treatment

Important Notice: The next available treatment period is commencing from Monday 17th June 2013.

In order to secure treatment in June it will be important to register for treatment by submitting your details below. This Initial Application Form will allow an initial screening to determine whether Radiowave Therapy may be a treatment option.

Patient's first name:

Patient's surname:

Patient's age:

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 Hormone treatment Other None

If other, please specify:

Please indicate if you require continuous home oxygen?

Yes No

Please indicate if you have a pacemaker or implantable defibrillator (ICD):

Yes No

Please indicate if you are confined to a wheelchair and require a two person hoist or transfer?

Yes No

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:

Yes No

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?

Yes No