Application | Immune Medicine

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

First Name(required)
Surname(required)
Age(required)
Date of birth(required)
Sex
Male Female
Usual Weight
Current Weight
Height
Blood Type

Address

Street
City
State
Zip
Telephone Home(required)
Telephone Work
Telephone Cell
Fax
Email(valid email required)
Occupation/Previous Occupation

Diagnosis

Please list what you have been diagnosed with and the dates the diagnosis was made.
Diagnosis
Method of diagnosis.
Metastases (Location and dates please).
Which of these best fits your current medical status?
Check any of these that apply to your
Constipation Jaundice Bleeding Fluids Pain
Bleeding, Fluid or Pain:
Did you check Bleeding, Fluids or Pain? If so please note the location here.
How's your appetite?

Treatment

Chemotherapy
Please list Chemotherapy type, date, dosages and number of courses
Radiation Therapy
Please list Radiation Therapy dates, dosages and number of courses.
Surgical Proceedures
Please list Surgical procedures, including dates, hospitals and procedure.
Current Supplements
Are you taking any supplements? Please list supplement, dosage, start date and end date.
List Current Medications
List current medications (prescription and over the counter) Please include dosage, start date and end date.

REQUIRED: Blood Test

Email a copy of your most recent blood test (CBC and Chem. Panel 24) along with a formal pathology report.

Thank you!

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