Cancer - Treatment against the cancer with GREEN SAP Drops

Please complete the next form, and you will receive the opinion of the Medical Center with the instruction of the treatment with GREEN SAP Drops.

* First Name :
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* Date of Birth :
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Contact :
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Clinical History:
Clinical Diagnostic:
Anatomopatological Diagnostic:

Surgery:	Kind of surgery:

Chemotherapy: Sessions:
Radiotherapy: Doses:
Tolerance to the medications :