Medical Referral

    Family name

    First name

    Date of Birth

    Sex

    Address (street/ house number/ area/ town/ country) Postal code/ country

    Phone (incl.area code)

    Email

    Attending physician (address, phone)

    Previous occupation

    What type of cancer do you have? (primary tumour/ metastases)

    Primary

    Metastases

    When was the tumor confirmed?

    Primary

    Metastases

    How did you first come across The Cancer Coach?

    Is there anyone in your family, who has had a tumor? State how the person is related to you/ type of tumor which was diagnosed

    Was your tumor removed?

    First surgery date

    Following surgery dates

    What type of therapy have you undergone? include medicines and date of medicines taken, whenever possible

    Are you currently taking any medicine, as part of a therapie? (if so, medicines and dates)

    Were any operations necessary after this course of therapy? (dates)

    We would like to draw your attention that we require your medical reports, diagnosises and any other relrevant information. With this information we can try to help you further.


    Please complete in block capitals

    Patient name

    Authorized person's name (if appropiate)

    Patient's date of birth

    Disease

    Please tick the option (only one) which best describes the patient's current health state

    Comments

    Declaration date

    Name of signing person

    Signature


    IF THE CANCER HAS METASTASIZED
    To what areas has it spread?

    LIST YOUR KNOWN ALLERGIES

    WHAT MAJOR SURGERIES DID YOU HAVE?

    HOW WOULD YOU DESCRIBE YOUR MOBILITY LEVEL? (Please check if applicable)

    LIST ANY ADDITIONAL PREVIOUS AND CURRENT MEDICAL CONDITIONS

    What kind of kidney disease and since when?

    What type, dose and duration

    What type, dose and duration

    What type, dose and duration

    What type, dose and duration

    Procedure date and additional information

    Time of implantation and model

    Location

    I HAVE A PORT (We recommend implantation of a port prior to treatment)

    Implantation Date

    PLEASE PROVIDE A BRIEF HEALTH HISTORY

    Please provide us with the following reports if you have them available. To upload the documents simply click the upload button and select the file to upload from your browser. (Each file size should not over 3MB and total file sizes should not over 15MB)

    YOUR ONCOLOGIST REPORT

    MRI/CT/PET SCAN REPORT

    LATEST LAB WORK/BIOPSY REPORT/HISTOLOGY

    ADDITIONAL REPORTS

    I confirm that the information provided in this questionnaire is an honest and realistic description of my/the patient's current health state. I understand that if my/the patient's health state on arrival differs significantly from the description given in this questionnaire, The Cancer Coach has the right to decline treatment and this may result in already paid costs not being refunded to me.

    Release and management of medical information: I understand that my medical information and records are kept confidential by The Cancer Coach.

    I agree and consent that The Cancer Coach may disclose all or any part of my medical records to a referring physician, hospital, clinic and/or medical center for the purpose of discharging their duties.

    I agree to release and hold harmless The Cancer Coach and its agent, representatives, employees from any and all liability associated with the disclosure of confidential patient information as authorized in this consent agreement and I do agree that The Cancer Coach is not responsible for the use or non-authorized disclosures of information by other to whom I have consented disclosures of my confidential information.

    I acknowledge that my medical information, treatment and all its history in kept in medical and electronic medical record. If I do not receive services or treatment from The Cancer Coach for 5 consecutive year, my medical records and other treatment records (including imaging records) may be deleted and/or destroy.

    I understand that this consent agreement will be valid and remain in effect as long as I am engaged with The Cancer Coach unless revoked by me in a written notice to the Authorized officer of The Cancer Coach

    I certify that I have read and understand this consent agreement and accept all of its contents.