Facility Update Form - DigniCap Scalp Cooling System

With so many changes in personnel lately, it’s time for us to update the information we have on your facility. This ensures we can continue to provide the highest level of personalized support to you, your team and patients. Please complete the brief form below:

Date

Submitted by

Facility Name

2. Oncology Information

Number of Infusion Chairs at your location

Number of New Solid Tumor infusion starts per month at your location

Number of Breast Oncologists at your location

Percentage of New Breast infusion starts per month at your location

Number of GYN Oncologists at your location

Number of GYN patients per year at your location

Hidden

Number of Breast patients per year at your location

3. Contacts

Navigator/ Educator primary contact

Navigator/ Educator contact email

Clinic primary contact

Clinic contact email

Infusion Room primary contact

Infusion Room contact email