To apply for assistance all information must be complete and include the following steps:

To Share Health Information: People, who work for MCF, may see my information and may use it only to help me get assistance with the costs of my drugs and to run the Program: Which may include the use of my photos, videos and information for the purpose of the campaign. I understand that the privacy of my information is of high priority and sequel to all precautionary measures taken by MCF to ensure protection of patient’s data, MCF would however not be liable in the event of accessibility of same by third parties via forceful or accidental extraction of same.

Attestation by Treating Physician

  • Patient Information
  • Patient Declaration & Authorization
  • Patient Consent
  • Attestation by Treating Physician

Patient Information

Full Names:

D.O.B (DD/MM/YYYY):

Nationality

State of Origin

L.G.A:

Address:

Marital Status

Phone

Gender

Occupation

How much do you earn monthly?

Email

Phone Number

Next of Kin Details

Name

Relationship

Phone

Email

Address

Other Details

Have you ever volunteered, supported any organization or done community services before?

Name of Organization

Date

Details:

Patient Declaration & Authorization

I declare:

I authorize the following communications:

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Max. size: 10.0 MB

Date

Patient Consent

Patient Name:

Patient Signature:

Date:

If applicable, your representative must sign below:

Patient Representative Name:

Email:

Phone:

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Max. size: 10.0 MB

Relationship to patient and authority to make medical decisions for patient:

Attestation by Treating Physician

Patient Name:

Gender:

Date of Birth:

Nationality

Hospital:

Hospital: No

Diagnosis:

Stage

Provide details of patient’s treatment plan and how many cycles patient will require

Doctor in Charge:

Contact Phone:

Email

I attest that the above named patient meets the eligibility criteria of this programme.

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Max. size: 10.0 MB

Date

More about us!

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Vision

Reduce Cancer Mortality rate by increasing cancer awareness and its preventive measures

Core Values

Passion, Empathy,
Consideration, Respect, Honesty,
Responsibility

Mission

To eradicate cancer and enhance the quality of life of the people living with cancer