Info Sheet | Arctic Cold Caps

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Personal Information
First Name Last Name
Date of birth
Contact Information
Email
Home Phone
Mobile Phone
Fax Number
Mailing Address
Street Address Address Line 2 City State ZIP Code
Spouse / Caregiver Information
First Name Last Name
Spouse / Caregiver Phone Number
Length Of Your Hair
Texture of Your Hair?
What Type Of Exercise Do You Do?
How Many Times A Week?
Notes

Cancer Details
Diagnosis
Chemotherapy Regimen
Please Explain Other
When is your infusion scheduled to begin?
How many weeks apart are your treatments?
How many rounds are you scheduled for?
Oncologist Information
First Name Last Name
Oncologist Phone Number
Oncologist Mailing Address City State ZIP Code

Oncology Treatment Center Information
Oncology Treatment Center
Oncology Treatment Center Phone Number
Treatment Center Mailing Address City State ZIP Code
Nurse Navigator Information
First Name Last Name
Telephone Phone

Credit Card Authorization
First Name Last Name
Address
Street Address City State ZIP Code
Phone
Credit Card Type
- Visa
- Mastercard
- Amex
- Discover
Credit Card Number*
Expiration Date*
Security Code*
Signature*

User Registration
Username*
User's First Name
User's Last Name
User's Email*
Password*
Enter Password Confirm Password