Salud Integral Treatment procedures

Medical Overview

In order for our medical staff to be able to accurately determine acceptability and proper dosage, patients will be required to submit their medical records to the offices of Salud Integral for review by our medical staff prior to being accepted for Anvirzel™ therapy.

Patients need to provide the completed Medical Overview Form and copies of their medical records that include physician report summaries of their current status and prognosis, medical history, evolution of disease and laboratory test results (Blood Work results and interpretations of Biopsy/Pathology, CAT Scans, MRI, PET etc.).

(Best completed in Google Chrome or Firefox Browser, you may get errors if viewed and completed in Internet Explorer Browser.)

Optionally, you may download, complete and return to us this pdfPDF Version of the questionnaire.
PLEASE NOTE: The Adobe Acrobat Reader or similar is needed to open and view this file.

  1. Patient Name*
    Please enter the patient's name
  2. Email:*
    Please enter a valid email address
  3. Age:*
    Please enter the patient's age
  4. Weight
    Invalid Input
    Please state unit, example: 100 pounds
  5. Height:
    Invalid Input
    Please state height unit, example: 5 feet 2 inches
  6. Sex:*
    Please make a selection
  7. Patient Address:*
    Please enter your complete address here
  8. Physician's Name:*
    Please enter the physician's name here
  9. Initial Diagnosis*
    Please enter your initial diagnosis here
  10. Date of Diagnosis*
    Please enter date of diagnosis
  11. Progression of the disease*
    Please describe the progression of the disease
  12. Current Treatment:*
    Please describe your current treatment here
    Describe and provide the start date, type, dose and response to treatment
  13. Other Medical Conditions:*
    Please enter other medical conditions of patient here
  14. Current Medications
    Invalid Input
    Please list all medications you are currently taking including: Medication name, dosage and condition prescribed for.
  15. Are you taking cardiac glycoside digitalis or digoxin?
    Invalid Input
  16. Performance Status (Please check only one)*

    Please select one from list which best describes the performance status of the patient.
  17. *
    Invalid Input
    Enter all the characters above in the field to the right.