Nutritional Supplement Request FormNutritional Supplement Request Form FROM: ST. LOUIS PEREGRINE SOCIETY 314-781-6775/FAX 314-781-6494 The Peregrine Society is happy to partner with you by providing nutritional supplements to cancer patients under your care. To qualify for this program, your patients' need must be associated with a current cancer diagnosis and/ or ongoing cancer treatments or related issues. Please complete this form and fax back to our office at 314-781- 6494.Request Made By(Required)Date(Required) MM slash DD slash YYYY Healthcare Agency Name(Required)Phone Number(Required)Fax NumberEmail(Required) Patient InformationPatient Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Is the patient diabetic?(Required)YesNoIs the patient enrolled in hospice?(Required)YesNoNutritional Supplement Need CriteriaOncologist Name(Required)Phone Number(Required)Cancer Dx(Required)Date of Dx MM slash DD slash YYYY Is patient undergoing radiation or chemotherapy?(Required)YesNoIf so, please list the start date MM slash DD slash YYYY and the end date MM slash DD slash YYYY Has there been excessive weight loss due to cancer dx?(Required)YesNoPlease explain reason for request (i.e. - cancer surgery, esophageal scarring, etc.)(Required)Supplement Requested(Required)BoostBoost PlusBoost Glucose ControlTube Feeding SupplementFlavor Vanilla ChocolateHiddenFlavorVanillaChocolateTube Feeding Product RequestedLength of time supplement will be needed(Required)3 months6 monthsAdditional Comments
