home : patient info [ schedule appointment :: directions :: information :: ]

PATIENT APPLICATION
Fill out the form below in order to schedule an appointment. You may also download this form, fill it out, and fax or mail it back to us.

Once we receive your application, the doctors will review it for scheduling.

We will contact you within 24-48 hours of receiving the application and schedule your consultation appointment. 

We will then send you a new patient packet for you to complete.  This packet outlines requested records we need prior to your appointment. (i.e., family history, labs, medical records, etc.) Since our clinical staff reviews your information before your consultation, it is critical that we receive this information at least three days prior to your appointment.

The consultation is quite comprehensive, therefore also we offer a video of the doctors during your consultation for a fee of $100.  See our FAQ page for a length of participating insurance companies.
Personal Information
Today's Date
Patient's First Name
* 		M.I.
 Last Name
*
Address
*
City
* 		State
* 		Zip
*
Home Phone Number
* 		Fax Number
Work Phone Number
 Email Address
*
Mobile Phone Number
Age
 Date of Birth
Social Security Number
Occupation
 Employer
Marital Status
Married
Single
Divorced
Widowed
 Spouse
Referred to Prostate Oncology Specialists by
 
Medical Information (What you do not have, please note as NA for Not Available
Diagnosis Date
* 		PSA at diagnosis
*
Gleason score
 If you have a pathology report, mail or fax it to us
Number of cores biopsied
 Number with PC in them
Results of digital rectal exam
Ploidy results from biopsy
(aneuploid, diploid, or tetraploid)
Ploidy results from RP, if done
PAP or other markers done after diagnosis
Bone Scan, if done (date and results)
CAT Scan, if done (date and results)
Endorectal MRI, if done (date and results)
Initial Treatment (Date and what was done - If RP, RT, or Hormone Blockade, provide as many details as possible
Subsequent Treatments (Provide as much detail as possible)
Current Therapy
Last Three (3) PSA results
Date 1
 Date 2
 Date 3
Result 1
 Result 2
 Result 3
Your Comments
 
Insurance Information
Primary Insurance
* 		Name of insured
*
ID Number
* 		Group Number
*
Customer Service Number
Secondary Insurance
 Name of insured
ID Number
 Group Number

Customer Service Number
 
Upload
If you have an insurance card in a digital format, you may upload it here:
If you have a pathology report, you may upload it here:
Other report you would like to upload: