PINC & STEEL Registration Patient Details Please tick the box that applies to you: I want to register for individual sessions. I am ONLY interested in attending group programmes (Targeted Class, Next Steps, PaddleOn, Online class) and do not wish to register for individual sessions. I am interested in both individual sessions and group programmes. Please complete the registration form below to be connected to your local certified PINC & STEEL Oncology Physiotherapist. We are currently experiencing higher-than-usual demand for our oncology rehabilitation funded sessions. In some regions, our available funding for this month has already been fully utilised. While we are actively working to secure additional resources, we may not be able to guarantee funded sessions at this time. If you have insurance coverage or are able to meet the cost of the initial assessment ($150), please indicate this on the registration form. We will then connect you to your closest certified Oncology Rehabilitation physiotherapist. Even without guaranteed funding, we encourage you to reach out, as the benefit of an assessment is invaluable. A physiotherapist can help tailor a rehabilitation plan to your individual needs, offering support and guidance through your recovery. We appreciate your understanding and remain committed to assisting as many people as possible through our programmes. Please select the relevant box: I can self-fund the initial assessment cost I need funding assistance for the initial assessment First Name Last Name Email Address Phone Number Gender Gender Female Male Don't know Prefer not to say Age Select your age Under 20 20-39 40-59 60-70 70-80 80+ Ethnicity Select your ethnicity New Zealand European Maori Samoan Cook Island Maori Tongan Niuean Chinese Indian Other Other (Please state) Street Address Address Line 2 Suburb City Region Select the region nearest to you Auckland Bay of Plenty Canterbury Gisborne Hawkes Bay Manawatu Marlborough Nelson Northland Otago Southland Taranaki Waikato Wellington Please provide details about the type of support you are seeking. Oncology History Diagnosis Select your diagnosis Breast Bowel Blood Gynae Prostate GI Cancer Kidney Lung Bone Sarcoma Head and Neck Skin Testicular Other If you have Ovarian Cancer please tick this box Diagnosis Date Surgery Yes No To come Type of Surgery Radiotherapy Yes No To come Chemotherapy Yes No To come Main reason for enquiry Already connected to a PINC & STEEL Physiotherapist and Clinic Name of Physiotherapist Name of Clinic If you do not have a Physiotherapist or Clinic, please write NONE above You must enable JavaScript to submit this form
