Total Management of Cancer Since 1969

Request for Patient Registration

Cancer Patients Aid Association (CPAA) provides a unique online platform to raise funds for patients. CPAA can assist the fund raising efforts of patients who require funds in large amounts by providing an online platform to accept financial support for treatment, from friends, relatives and well-wisher as they may be inclined to give more readily to an organisation who can give them a tax exemption certificate for the amount donated rather than an individual.

To register a patient with CPAA's online donation gateway, kindly fill in the form below. On verification the case will be put up on the Donation Gateway.

Funds received will be ear-marked for the said patient and transferred to the patient's bank account against original bills for expenditure incurred towards treatment and medication subject to our terms and conditions. It is mandatory for the patient's family to update CPAA of the patient's progress via email or telephone every 3 months from the time of enrollment. In the absence of the above, the case details will be removed from the website.

Patient's name:*
First name: *

Last name:*

Patient's next of kin (spouse, parent, relative or guardian)

Contact number

Date of Birth:*

Profession (tick one): *


Address: *

City: *

Pin Code: *

Country: *

Contact Number:*


Email ID:

Patient's Income (Rs. /per month):

Total Family Income (Rs. /Annual):

Patient’s diagnosis:

Family Description (Parents and Siblings)


Relation with patient




Treatment first started on:

Relapse if any:

Estimated Duration of treatment:


Estimated Treatment cost (Rs.):

Expenses incurred to date(Rs.):

Treatment details:
Name of Hospital:


Doctors Full Name:

Doctor’s Registration No. :

Upload Documents:
A scan of recent passport-sized photograph of the patient:

Cost certificate from the Hospital:

Doctors report of the prognosis:

Copy of Aadhar card / PAN Card :

Document to declare income (IT returns, Income certificate etc) :