Patients Form

    Patient’s name*

    Age*

    Gender

    Type of cancer, tumour & tumour location

    Is the tumour cutaneous or subcutaneous?

    Approximate size of tumour, if known

    Previous treatment details

    Chemotherapy

    Drug used

    Total quantity of drug given

    Radiation

    Is there a recurrence? If yes, how many times?

    Treated with ElectroChemoTherapy earlier

    If yes, what was the response?

    City/Town

    Country

    Contact

    Email

    Attach scanned/electronic reports