Required *

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Basic information

Gender (patient) Choose a value Female Male

First name (patient)

Last name (patient)

Age (patient)

Town

Country

Email

Agreement

Yes, I agree to the processing of my personal data - in accordance with the privacy policy - to process and respond to this request.(Your data will be treated confidentially.)

Phone

Fax

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If another person is writing for patient - Writer's name:

Prefix (Helper) Choose a value Ms. Mr.

First name (helper)

Last name (helper)

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Information regarding your former health situation:

What kind of original cancer was diagnosed?

Date of first recognized indications?

Therapies carried out so far:

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Information regarding your current health situation:

Known metastases existent? If yes: Where?

Current situation?

Patient's current condition? (please select one) Choose a value 100: Normal 90: Able to carry on normal activity; minor symptoms of disease 80: Normal activity with effort; some symptoms of disease 70: Cares for self; unable to carry on normal activity or active work 60: Requires occasional assistance but is able to care for needs 50: Requires considerable assistance and frequent medical care 40: Disabled; requires special care and assistance 30: Severely disabled; hospitalization is indicated 20: Very sick; hospitalization necessary; active treatment necessary 10: Moribund; fatal processes progressing rapidly

Other current illnesses:

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Other patient information:

Patient needs special care...

Patient could travel to Frankfurt am Main:

YesNo

Patient would come

alonenot alone

Accomodation wanted... Choose a value none cheap as possible mid standard high standard

Patient would like to have more information regarding the ...

chances of treatment by Gerhard Siebenhüner
estimated duration for treatment in Frankfurt
estimated duration for repeat treatment
estimated costs for treatment
results to be expected

Personal communication to Gerhard Siebenhüner: