E-mail (Please use the same e-mail you used for registration)
*
example@example.com
Patient data
Name
*
First name
Surname
Gender
*
male
female
Age
*
Cancer type
*
When was the cancer first diagnosed?
*
Is the patient able to swallow?
*
yes
no
Is the patient bedridden?
*
yes
no
Would the patient be fit to travel?
*
yes
no
Brief medical history
*
Please upload your reports here.
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