NEOK Patient Intake Form

Radiation Oncology New Patient Information
DateTime
Name*

First NameLast Name
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Gender*
Before you were referred to us did you know that there was a cancer center in Claremore?*
Besides your referring physician, where else have you heard about us? (Check all that apply)*

FacebookOur WebsiteCommercialGoogleAdvertisementsCommunity EventNoneOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Preferred Pharmacy:*
Name of Primary Care Provider*
Other Physicians (surgeon, oncologist)
Problem/Reason for Visit*
Occupation/Year of Retirement*
Emergency Contacts:
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship*
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship
In accordance with the Health Insurance Portability and Accountability Act (HIPAA), I agree that Northeastern Oklahoma Cancer Institute and its authorized agents and employees may disclose protected health information directly relevant to involvement with my care, or payment related to my care, to my emergency contacts, who may contact Northeastern Oklahoma Cancer Institute on my behalf.
Initials*

Clear
I understand and agree to allow my name, photograph, story, and video/audio to be used in any number of marketing purposes and communication vehicles to promote Northeastern Oklahoma Cancer Institute (NOCI).

I release NOCI and those acting pursuant to its authority from liability for any violation of any personal or proprietary right I may have in connection with all such recordings and uses without my inspection; images will remain the property of NOCI.
Initials*

Clear

	Responses
Age of first menstrual cycle
Usual Duration
Heavy, Medium, Light
Date of last menstrual cycle
Number of live births
Number of c-sections
Age of first pregnancy
Number of miscarriages
Number of still births

	Responses
Number of packs per day
How many years
Do you still smoke
Any other tobacco use
Exposure to second hand smoke

	Responses
How much
How many years
Hard Liquor
Beer

Patient Financial Responsibility Agreement

At Northeastern Oklahoma Cancer Institute, we truly appreciate the opportunity to provide you with compassionate, state-of-the-art care. This Agreement identifies your financial obligations for all the services you receive from us, including the services provided today and in the future. Please let us know if you do not understand any of the items discussed in this agreement.
- Please inform us of ALL insurance coverage you possess, and of any recent changes. This is crucial for proper billing and to ensure insurance coverage for our services, when available. We need correct and current information on a timely basis. If your insurance coverage changes, please contact our office immediately at 918-283-4078.
- If you do not have insurance, a payment plan can be established via our business office.
- At your request, a financial counselor can provide you with an estimate of your financial responsibility for your treatment. However, please understand that an estimate is not binding and that the actual cost may be different. You are personally responsible to us for the full payment of all services you receive from us. Our business office accepts payment for daily co-pays via cash, check, or credit card.
- We will submit a claim to your primary and secondary insurance for all services that we provide to you. If we do not receive payment within 30 days of submission or your insurance notifies us that you are not covered under your insurance plan (e.g. the services were not pre-authorized), you will pay us the outstanding balance of the services. We will send you a statement for the amount due. If your account, including reasonable attorneys’ fees and collection costs. If we eventually receive a payment from your primary or secondary insurance, we will refund the difference to you.
- You authorize and direct any insurance proceeds payable for services provided by us to you to be paid directly to us, and assign to us, without recourse, all interest in and rights to claim, collect and receive the proceeds from any insurance company providing coverage for our services. You authorize any insurance company to furnish to use and our agents all information pertaining to your insurance benefits and the status of all claims submitted by us.
- We are Medicare providers and accept assignments from Medicare. However, there may be a balance due from you after Medicare pays. Medicare law prohibits us from waiving this balance.
I have read this Agreement, understand its content, and agree to its provisions.
Signature*

Clear

Authorization to Obtain Medical Records

By signing and dating the fields below you authorize us to obtain medical records as it pertains to your care in our center.
Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

	Yes	No
Any pregnancy complications
Are you pregnant now
Regular menstrual cycle
Birth control
Painful intercourse
Tubal Litigations
Did you breastfeed

	Yes	No
Prostate Trouble
Change in size of testicle
Difficulty having erections
Discharge from penis
Testicular Pain
Breast Lump

	Yes	No
Tonsillectomy
Appendectomy
Gallbladder
Hysterectomy
Bronchoscope
Lung Surgery
Breast Biopsy
Mastectomy
Colon/Rectal Surgery
Prostate
Hemorrhoidectomy
Pacemaker

	Yes	No
Head Headaches
Fainting Spells
Dizziness
Nose Nose Bleeds
Sinusitis
Post Nasal Drip
Eyes Double Vision
Pain In Eyes
Changes in Vision
Ears Drainage from ear(s)

	Yes	No
Heart Chest Pain
Pressure Attacks
Pain or cramps in legs when walking
Shortness of breath when lying flat
Swelling of feet or ankles
Lung Excessive/colored phlegm
Cough (Frequent)
Wheezing
Endocrine Night-sweat
Change in scalp/body hair
Poor tolerance of cold
Abnormal thirst
Enlarged glands (neck, under arms)
Hot flashes

	Yes	No
Excess gas
Vomiting blood
Constipation
Any black, tarry stools
Yellow jaundice
Weight changes > 10 lbs in 6 months
Heart burn
Nausea
Diarrhea
Any bloody stools
Any mucous in stools
Change in bowel habits
Trouble eating raw,greasy, spicy foods

	Yes	No
Musculoskeletal Muscle weakness in arms
Swollen joints
Painful joints
Pain/aches in muscles
Neurological Difficulty with balance/walking
Tremors/Shakes
Loss of coordination
Loss of consciousness
Paralysis
Tingling/numbness
Speech difficulty
Genitourinary Pain/burning during urination
Cloudy urine
Difficulty passing urine
Blood in urine
Difficulty controlling urine
Urination during the night

	Yes	No
Eyes Poor vision corrected by glasses
Glaucoma
Cataracts
Night blindness
Ears Buzzing or Ringing in ears
Deafness
Hearing Difficulty
Head Migraines
Tension Headaches

	Yes	No
Heart Heart murmur
Rheumatic fever
High blood pressure
Heart failure
Fainting spells
Heart Attack
Anemia
Blood transfusions
Poor circulation
Lung Bronchitis
Tuberculosis
Pneumonia
Emphysema
Pleurisy

	Yes	No
Gastrointestinal Liver disease
Hemorrhoids
Gallbladder Disease
Endocrine Thyroid Trouble
Poor tolerance of heat
Hearing Difficulty
Musculoskeletal Gout
Arthritis
Genitourinary Any kidney infection
Gonorrhea
Syphilis
Any bladder infections
Kidney stone
Neuro Stroke

	Medication	Dosage	How many times per day
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication