Apply for Treatment

Treatment Application

Please complete this form to begin your application process. Our medical team will review your information and contact you for a complimentary evaluation.

Patient Information

First Name *

Last Name *

Email *

Phone *

Date of Birth *

Preferred Contact Method

Address

City

State/Province

ZIP/Postal Code

Country

Medical Details

Cancer Type *

Cancer Stage *

Diagnosis Date *

Current Treatments

Previous Treatments & Outcomes

Current Medications

Medical History

Eligibility Confirmation

I confirm that I have been diagnosed with a solid tumor that can be biopsied (blood malignancies such as leukemia are not currently treatable)

I have a stable, functioning immune system

I am able to travel to Las Vegas, Nevada for treatment

I am available for the 6-week treatment cycle (three treatments, two weeks apart)

Medical Documents

Please upload the following documents. Accepted formats: PDF, JPG, PNG, DICOM (max 10MB per file)

Pathology Report

Imaging Scans (CT, MRI, PET)

Recent Lab Results

Medical Records

Emergency Contact

Name

Phone

Relationship