Cap & Conquer: Applying for Funding
We understand how much you are going through right now and the last thing we want to do is add stress to your journey. However, we only have finite resources so we want to make sure we give appropriately and fairly. If you have any questions about this form or the application process in general, please email us at info@capandconquer.org.
Sign in to Google to save your progress. Learn more
Email *
What is your name? *
What is your date of birth? *
What is your Street Address? *
What is your City, State and Zip code?  *
What is your phone number? (PLEASE PROVIDE A CELL PHONE NUMBER. We will text or call in the next 24 to 48 hours!) *
To which gender do you most identify? *
Which race or ethnicity best describes you? (Please choose only one).
 *
How did you hear about us? *
What is your cancer diagnosis? *
Where are you receiving treatment? *
Who is your oncologist? *
There are some cancers that do NOT permit the use of cold cap therapy during treatment. There are also some oncologists that do not support the use of cold cap therapy. By clicking "I agree", you are confirming that you have spoken to your doctor and been given explicit approval to use cold caps during your treatment. 
 *
What chemotherapy regimen will you be receiving? *
How many treatments will you be receiving and how often? (e.g., once every two weeks) *
What is your estimated start date of chemotherapy? (If unknown, please put N/A)  Please note, we do NOT, in any circumstance, allocate funding after chemotherapy has started.  *
What type of cold cap will you be using? *
Who is your health insurance provider? *
Have you asked your insurance provider if they cover cold caps? 
These are the codes you could inquire about: 

-Suggested ICD diagnosis codes include: Z51.11 (Antineoplastic chemotherapy) L65.9 (Nonscarring hair loss unspecified, chemotherapy induced alopecia)

-Suggested CPT codes include: A9273 (Ice cap, cold wrap or pack), A9282 (Wig any type, Cranial/scalp prosthesis)

-Durable Medical Device code 0662T

 *
What is your occupation? *
What is the size of your household (number of people living in your home including yourself)? *
What would you estimate your monthly household gross income to be? *
What would you estimate your monthly gross household expenses to be? *
What subsidy amount would allow you to use cold cap therapy? PLEASE NOTE THAT WE DO NOT PROVIDE 100% FUNDING FOR MANUAL COLD CAPS. 
 *
Are you interested in having a dedicated mentor to communicate with about cold capping?  *
Please tell us more about your financial situation and why you need Cap & Conquer's assistance to afford scalp cooling. *
Scalp cooling, especially if you use the manual caps, requires a lot of support. Tell us about your support system and, if you're doing the manual caps, who your capper will be. *
Please use this space to include anything else you would like us to know about your situation (or you!) so that we can help you in the best way that we can. *
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms