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(Surname First):

Date of Birth

Nationality

State of Origin

Local Government

Address:

Marital Status

Phone

Gender

Occupation

How much do you earn monthly?

Email

How did you learn about this program?

Type of cancer diagnosis?

Stage of cancer ?

How do you think this program will benefit you?

Next of Kin Details

Name

Relationship

Phone

Email

Address

Other Details (Please Fill Below)

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

Name of Organization

Date

Details:

ACCESS NEEDS

Chemotherapy: (in this section, Patient can Choose more than one):

Diagnosis

Date of Diagnosis

Pathology Testing

Radiological Investigation

Please upload your IHC results

Max. size: 10.0 MB

Have you taken any of the selected drugs before?

Kadcyla 100mgVial 1

Xeloda 500mg 120 TAFI

Mabthera Vials 1400mg/11.7ml 1

Mabthera Vials 500mg/50ml 1

Mabthera Vials 100mg/10ml 1

Avastin 100mg 1

Avastin 400mg 1

Perjeta Vials 420mg/14ml 1 + Herceptin 600mg 1 SC

Herceptin 440mg 1

Herceptin 150mg 1

Herceptin SC 600mg 1 SC

Docetaxel

Eloxatin

Ibrance (in view)

Zoladex (in view)

Patient Declaration & Authorization

I declare:

I authorize the following communications:

Upload Signature

Max. size: 10.0 MB

Please Upload Medical Record

Max. size: 10.0 MB

Please Upload means of Identification (Int'l Passport, National ID, Voters' Card, Drivers' License)

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:

Upload Signature

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.

Upload Signature

Max. size: 10.0 MB

Please Upload Medical Report

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