Questions about chemotherapy and radiation therapy

1. Are you undergoing chemotherapy treatment?

If so, what is the start date and estimated duration?

For which of these services do you need our advice?

Hair loss

Breast surgery

Both of these 2 services

For the hair loss service, please send us photos of your hair before starting the chemotherapy treatment (color, style, length of your hair).

Max. file size: 300 MB.

3. Have you had surgery?

If yes, which surgery did you have?

If yes, what was the date of the surgery?

4. Are you undergoing any other medical treatment? Specify the type of treatment.

If yes, what is the start and end date of the treatment?

5. At which hospital are you being treated?

6. Do you have any swelling or redness?

If yes, where is it and describe it?

7. Do you have any other issues?

If yes, specify?

8. Do you need adaptive clothing or compression bandages?

If applicable: What size bra do you usually wear?

If applicable: Did you gain or lose weight?

9. What are your expectations?

10. How did you hear about us?

Have you been referred? If yes, specify

First name

Last name

E-mail

Postal code

Telephone (preferably cellphone)

When is the best time to reach you?

Day

Evening

Weekend

Cancer information form