Get Patient Intake Form - Potomac Radiation Oncology

Filling out the Patient Intake Form is a crucial step in your journey at Potomac Radiation Oncology. This guide provides clear, step-by-step instructions to help you complete the form online with ease and accuracy.

Follow the steps to successfully complete the Patient Intake Form online.

1. Press the ‘Get Form’ button to access the form and open it in your chosen document editor.
2. Begin by entering your personal details. Fill in your full name and the date of your visit in the designated fields.
3. Provide your contact information. Enter your home, work, and cell phone numbers, and ensure your email address is accurate.
4. List your address clearly, ensuring all parts are completed.
5. Indicate your insurance provider(s) by writing the relevant details.
6. Choose whether you would like to receive personal messages via voicemail or email.
7. Select your marital status and provide the name of the person you live with.
8. Input your Social Security Number (SSN), date of birth (DOB), and current age.
9. Indicate your employment status by selecting the relevant option.
10. If applicable, grant permission for the office to speak with select relatives or friends by listing their names and relationships.
11. Fill in your emergency contact information, including their name, relationship, and phone number.
12. Provide details about your current or former occupation.
13. Input the name and phone number of your referring physician.
14. List your primary care physician along with their contact number.
15. Include names and phone numbers of any other physicians you wish to keep informed.
16. Clearly state the reason for your visit.
17. Fill out the medical information section, which includes your height, weight, any recent weight loss, and pain status.
18. Indicate your smoking habits and alcohol consumption.
19. List any drug allergies and current medications, including dosage and frequency.
20. Document any major medical problems you have, prior surgeries, and hospitalizations.
21. If relevant, provide details about previous radiation treatments or chemotherapy.
22. Discuss any family history of cancer.
23. Enter your pharmacy name and their phone number.
24. Confirm whether you have an implanted medical device and list details if applicable.
25. Complete the review of systems section by marking any symptoms experienced in the last 30 days.
26. Once all fields are completed, save your changes, then download, print, or share the form as needed.

Complete your Patient Intake Form online today for a smoother appointment process.