Get Va Potomac Radiation Oncology Center Patient Intake Form 2020-2025

Completing the VA Potomac Radiation Oncology Center Patient Intake Form online is a crucial step in preparing for your visit. This guide will walk you through each part of the form, providing clear instructions to ensure a smooth and efficient experience.

Follow the steps to complete the form successfully

1. Press the ‘Get Form’ button to access the form and open it in your preferred document viewer.
2. Begin by filling in your patient name and visit date at the top of the form. These details are essential for identifying your records during your appointment.
3. Enter your contact information, including your home, work, and cell phone numbers. Accurate information allows for effective communication regarding your care.
4. Provide your home address and email address. Indicate whether you would like to be contacted via email by selecting 'Yes' or 'No'.
5. Select the preferred options for the clinic to leave personal messages on your voice mail for your home, work, and cell numbers.
6. Indicate how you heard about the Potomac Radiation Oncology Center. Choose between options such as from a referring physician or another source, providing additional details if applicable.
7. Fill out your marital status and whom you live with. Include your social security number, race, and county to provide necessary demographic information.
8. Enter your date of birth and age. Confirm your employment status and provide details of your current or former occupation.
9. List your referring physician and primary care physician, including their names and phone numbers.
10. Identify any additional physicians you would like the center to keep informed about your care.
11. Explain the reason for your visit and provide relevant medical information including height, weight, recent changes, pain levels, smoking status, alcohol consumption, and previous treatment history.
12. Document your current medications, their purpose, the dosage, and frequency of use. Specify your pharmacy information for prescriptive needs.
13. Mention any significant medical problems, prior surgeries, and hospitalizations you've had.
14. Accurately answer all questions regarding any history of cancer in your family and if you have an implanted medical device.
15. Provide contact information for emergency contacts, including their name, relationship, and phone number.
16. Lastly, review the symptoms checklist and mark any symptoms you are currently experiencing or have experienced in the last 30 days.
17. Once all sections are filled out, ensure to review your information for accuracy. You can then save any changes, download, print, or share the form as needed.

Take the next step in your healthcare journey by completing the VA Potomac Radiation Oncology Center Patient Intake Form online today.