Patient Intake Form

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Registration Received!

Thank you for registering. A Cancer and Hope coordinator will contact you within 24–48 hours via your preferred contact method.

Maraming salamat sa inyong tiwala. Makikipag-ugnayan sa inyo ang aming coordinator sa loob ng 24–48 na oras.

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1. About the Patient

First Name * Please enter the patient's first name.

Last Name * Please enter the patient's last name.

Age * Please enter the patient's age.

Sex at Birth * Please select sex at birth.

Location * Please enter the patient's city/province.

2. Medical Information

Type of Cancer * Please select a cancer type.

Cancer Stage (optional)

It's okay if you don't know your stage yet. Our specialists can help determine this from your medical records.

Approximate Date of Diagnosis (optional)

Treatments Received So Far (select all that apply — optional)

Surgery Chemotherapy Radiation Therapy Targeted Therapy Immunotherapy Hormonal Therapy No treatment yet

Current Medications or Ongoing Treatment (optional)

Brief Medical Summary (optional but helpful)

You may also bring or email your pathology report, imaging scans, or doctor's notes — these will help the specialist greatly.

Your Questions for the Doctor (optional)

3. Contact Information

We will use this information only to contact you about your registration. We will never share it with third parties.

Mobile Number *

Please enter a mobile number.

Email Address * Please enter a valid email address.

Preferred Contact Method * select all that apply

Phone Call Email Viber Message WhatsApp

Please select at least one contact method.

Best Time to Contact You (optional)

Preferred Communication Language (optional)

4. Consent & Acknowledgment

🔒 Your information is treated with complete confidentiality. We collect only what is needed to connect you with a specialist. We will never sell or share your data with advertising companies or unauthorised third parties. You may request deletion of your information at any time by contacting us.

A coordinator will contact you within 24–48 hours after receiving your form.

Makikipag-ugnayan sa inyo ang coordinator sa loob ng 24–48 na oras.

Your Privacy is Protected