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Application | Immune Medicine

Application

Complete this form as best you can. Don’t worry if you don’t have access to all details as we’ll be in contact shortly and can discuss any matters you feel relevant. Your medical history is kept as part of your confidential patient records and is considered your property.

IAT Online Application
  1. (required)
  2. (required)
  3. (required)
  4. (required)
  5. Sex
Address
  1. (required)
  2. (valid email required)
Diagnosis
  1. Please list what you have been diagnosed with and the dates the diagnosis was made.
  2. Check any of these that apply to your
  3. Did you check Bleeding, Fluids or Pain? If so please note the location here.
Treatment
  1. Please list Chemotherapy type, date, dosages and number of courses
  2. Please list Radiation Therapy dates, dosages and number of courses.
  3. Please list Surgical procedures, including dates, hospitals and procedure.
  4. Are you taking any supplements? Please list supplement, dosage, start date and end date.
  5. List current medications (prescription and over the counter) Please include dosage, start date and end date.
REQUIRED: Blood Test
  1. Email a copy of your most recent blood test (CBC and Chem. Panel 24) along with a formal pathology report.
Thank you!
  1. Please let us know how you found out about IAT
 

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