Medical Questionnaire

Integrative Cancer Centers of America

To request an appointment, please begin the new patient appointment process by completing the form below and one of our Patient Directors will contact you.

First Name, Last Name *

Your e-mail address *

Phone Number *

Nearest Major City *

Territory *

Gender *

Height *

Weight *

Age *

Referring Party

How did you hear about us? *

Stage of Cancer of progression (if applicable)

Primary Cancer and date of diagnoses *

Organs and/or areas of metastasizes

Describe all cancer related treatments

Current medications and non-prescriptions

Recent diagnostic or therapeutic x-ray or ct scan, radioisotope

Remarks