Patient Registration - Cancer Guidance Program

ONCORG invites you to share information about you and to let us know how we help you.

We understand how intimidating it can be when diagnosed with cancer. We have access to over 2,000 cancer treatment centers and dozens of clinical trials that can be beneficial to you; no matter what type of cancer you have or what stage you're in.

We are a community to help you on your cancer journey. We lean on this integrated community to ensure every possible treatment option is explored to benefit you. We give you practical advice because we have access to more treatment options than any other platform, and we do so in a personal and caring manner.

1. Personal Information

Full Name *

Date of Birth *

Age *

Gender *

Male

Female

Other

Marital Status

Address

City

State

PIN Code

Phone Number *

Email Address *

2. Emergency Contact

Name *

Relationship *

Phone Number *

3. Medical Information

Primary Diagnosis (Type of Cancer) *

Date of Diagnosis *

Stage (if known)

Stage I

Stage II

Stage III

Stage IV

Unknown

Treating Hospital/Oncologist

Hospital Contact No.

Current Treatment

Chemotherapy

Radiation

Surgery

Immunotherapy

Hormone Therapy

Palliative Care

Surgical Oncology

Current Medications

Allergies (if any)

4. Guidance Required

Please select the type of support/guidance you are seeking:

Treatment Options Counseling

Second Medical Opinion

Emotional / Psychological Support

Nutritional Guidance

Financial / Insurance Assistance

Palliative / End-of-Life Care Guidance

Transportation / Lodging Assistance

Support Group Enrollment

Request to be referred to a clinical Trial

Other Guidance Required

5. Consent

Consent Date *

Patient Registration Form

1. Personal Information

2. Emergency Contact

3. Medical Information

4. Guidance Required

5. Consent