Information Sheet

Arctic Cold Cap Therapy

Please complete the form below and a Arctic Cold Caps representative will call to get you started. Please fill out all the information you know. Call us if you have any questions or concerns.

Personal Information

Name:

Date of Birth:

Contact Information:

Mailing Address:

Spouse / Relative Information:

Notes:

Cancer Details

Diagnosis:

Regimen:

When is your infusion scheduled to begin? :

How many weeks apart are your treatments? :

How many rounds are you scheduled for? :

Oncologist Name:

Oncologist Phone Number:

Oncologist Mailing Address:

Oncology Treatment Center:

Treatment Center Mailing Address:

Nurse Navigator: