Patient Registration

WIN Cancer Foundation — Nigeria

Why Register With Us?

WIN Cancer Foundation Nigeria is committed to walking alongside every cancer patient on their journey. By registering, you help us understand your needs so we can connect you with the right support — whether that is information, community, or resources available in your area. Your information is kept strictly confidential and is only used by our team to reach out and support you.

After you submit this form, your details go securely to the WIN Cancer Nigeria team. A team member will review your registration and reach out to you directly.

Personal Information

First Name *

Last Name *

Date of Birth *

Gender *

Phone Number *

Email Address *

Location (optional)

Street Address

City / LGA

State

Medical Information

Both fields below are required — you cannot submit without them.

Cancer Type *

Year of Diagnosis *

Additional Details (optional)

Stage of Cancer

Treatment Status

Hospital / Treatment Centre

Doctor / Oncologist Name

Type of Treatment

Additional Notes

I consent to WIN Cancer Foundation Nigeria storing and using my information to contact me and provide support. My information will be kept confidential and will not be shared with any third party. *

Fields marked * are required.

After submission, your registration is securely stored and reviewed by the WIN Cancer Nigeria team. A team member will reach out to you.

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