Berkeley Institute International - Enrollment Criteria

HOME > How to Enroll

How to Enroll

To inquire if you qualify for our therapy, please fill out the following form. We often receive emails from friends and relatives lacking complete information.  Friends and relatives often will not have the information requested below.  If not providing us complete information, please always include your telephone number so that we can speak with you.

If you do not get a reply within 48 hours, please give us a call at (510) 250 5990.  This number cannot give you any medical information, but someone will return your call if you leave a phone number.

  1. Your first, middle and last name.
  2. Your e-mail address.
  3. Your postal mail address including City, State, Country and Zip Code.
  4. Your occupation.
  5. Your phone number.
  6. Your date of birth.
  7. Your gender.
  8. What kind of cancer are you diagnosed with?
  9. When was it discovered?
  10. Please briefly describe your first treatment.
  11. Did the cancer recur?
  12. Please briefly describe your current condition.
  13. What were the results of your last CT scan?
  14. Please list your complete current medications.
  15. On a scale 1-10, what is your current level of activity (10=very active).
  16. If you had to travel, would you have someone to accompany you?
  17. Have any children under the age 18?
  18. Please briefly further describe yourself and your situation.
  19. How did you hear about us?

Click here back to home page.

1/24/14


Copyright © 2010-2017
Berkeley Institute International
All Rights Reserved.

Bay Area web design by
Verecom.com   ·   WWWizard.com