CANHELP: A cancer treatment referral and information clearinghouse

To Order a Personalized Report

(Please note: This is a secure form and your information will be kept confidential)

The following information is required:

A cover letter containing a brief chronological listing of the important facts of your illness including your current medical status.
List all treatments to date including alternative therapies.
A copy of any pathology report(s), current imaging reports (X-ray, CT and MRI scans), blood work (if applicable), and surgical reports. Please DO NOT send actual slides, X-rays, or scans.
If you have any specific questions, please include them in your cover letter.
Payment by check, money order or major credit card (American Express, Master Card, Visa and Discover) must accompany medical records.
If you charge the fee to a credit card, you may fax the records to us directly at (360) 437-2272 along with a copy of this form, or you may send records and a check, made payable to CANHELP, Inc., via next day courier to:

CANHELP, Inc.
3111 Paradise Bay Rd.
Port Ludlow, WA 98365.

CANHELP Fee Schedule

US Clients Outside of the US

7-10 Day Report $400 $500

2-3 Day Express $550 $650

Return of Records $25 $35

Note: The above fee schedule includes follow-up telephone consultations for one year. We ship our report packages by next day courier. Shipping is included.

Please, double check your completed form for accuracy. Once we receive your order, you will receive e-mail or telephone confirmation.

Your Name (Required Field)

Email address (Required Field)

Name of Client

Age, Date of Birth, Sex

Report Address, (street, city, state, and zip code)

Please describe your cancer and condition as accurately as possible including type, stage and current status

Telephone:
Home Fax
Alternate Telephone Cell Phone

Choice of Payment (Required Field)

Check
Credit Card
Money Order
Type of search?

Express (2-3 business days) $550
Regular (7-10 business days) $400
Express-International clients (2-3 business days) $650
Regular-International clients (7-10 business days)$500

Type of credit card

American Express
Visa
Master Card
Discover

Credit Card Number

Credit Card Expiration Date:

Credit Card Billing Name and Address

Credit Card Holder's Telephone

Date Sent

Any comments?

Click on Submit when ready to send.

NOTE: If you have any problems submitting this form, please call us at:
(800) 565-1732.

Thank you.