If you would like to know if Hope Therapy is an option for you, please complete the following (note that there is no cost for this initial assessment).

Patient's First Name

Please type patient's First Name

Patient's Surname

Please type patient's Surname

Patient's date of birth:

Please type patient's date of birth

Patient's Phone Number:

Please type patient's Phone Number

Patient's Email Address:

Please type patient's Email Address

Problem:

Please type Type of Cancer

Date of first diagnosis:

Please type Date of first diagnosis

Have you had any form of treatment (tick one or more boxes)

Chemotherapy Surgery Radiotherapy Hormone Treatment Other None Please select at least one type of treatement.

If other, please specify:

Please indicate if you require continuous home oxygen?

Yes No Please select Yes or No

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

Yes No Please select Yes or No

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

Yes No Please select Yes or 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 Please select Yes or No

Details of Person completing this form on behalf of the patient:

Name:

Please type your Name

Phone Number:

Please type your Phone Number

Email Address:

Please type your Email Address

Do you wish to be the primary contact person?

Yes No Please select Yes or No

Enter the Security Code seen Above:

Please Enter Security Code