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):
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?
How did you learn about this program?
How do you think this program will benefit you?
Next of Kin Details
Name
Relationship
Phone
Address
Other Details
Have you ever volunteered, supported any organization or done community services before?
Name of Organization
Date
Details:
Have you taken Herceptin before?
Have you taken Herceptin before?
If yes, How many vials have you had?
How and where did you purchase?
Patient Declaration & Authorization
I declare:
I authorize the following communications:
Upload Signature
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:
I attest that the above named patient meets the eligibility criteria of this programme.
Upload Signature
Max. size: 10.0 MB
Date
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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