Advocate Radiation Oncology Website

Formulario de Registracion

Registration Form

"*" indicates required fields

1Patient Registration

2Medical History Forms

3Medication Consent

4Family History

5Preventative Health Maintenance

6Symptoms

7Depression Screening

8Advance Directives

9General Consent

10Medical Records Release Form

11Review/Submit

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Confirmation Number

Patient Registration

*Asterisk indicates required field

PATIENT NAME (LAST -- FIRST -- MIDDLE INITIAL)*

First Middle Last

Patient Email

Patient Home Phone

Patient Cell Phone

Patient Cellphone - Is it an iPhone?

Yes

Patient Address*

Street Address City State ZIP Code

Patient Date of Birth*

MM slash DD slash YYYY

Patient SSN

Gender*

Male

Female

Marital Status*

Single

Married

Other

Patient Employer Name

Patient Employer Address

Street Address City State ZIP Code

Patient Employer Phone

Insured/Responsible Party Information

Insured/Responsible Party Name

First Middle Last

Relationship to Patient

Insured/Responsible Party Address (if different from patient)

Street Address City State ZIP Code

Insured/Responsible Party Home Phone

Insured/Responsible Party Cell Phone

Insured/Responsible Party SSN

Insured/Responsible Party Birth Date

Insured/Responsible Party Employer

Insurance Information

Primary Insurance Name*

Primary Insurance Address (from the back of the insurance card)

Street Address City State ZIP Code

Primary Insurance Group Number

Primary Insurance ID Number

Primary Insurance Type

HMO

PPO

Primary Insurance Phone

Secondary Insurance Name

Secondary Insurance Address (from the back of the insurance card)

Street Address City State ZIP Code

Secondary Insurance Group Number

Secondary Insurance ID Number

Secondary Insurance Type

HMO

PPO

Secondary Insurance Phone

Admission Information

Primary Doctor/Family Doctor

Referring Doctor

In Case of Emergency Contact

First Last

Emergency Contact Relationship

Emergency Contact Phone

Are you currently admitted to a hospital or enrolled in a Hospice or Skilled Nursing Facility?

Yes

Facility Name

Facility Phone

Facility Address

Street Address City State ZIP Code

Are you receiving benefits from the Veterans Administration?

Yes

VA Name

VA Phone

VA Address

Street Address City State ZIP Code

Which of the following best describe your race?

Asian

Caucasian

Black / African American

Hispanic

Subcontinent Asian American

Asian Pacific American

Native American

American Indian / Alaskan Native

Hawaiian

Pacific Islander

More than one race

Other

Decline

Please select one ethnic group that best describes your race:

Hispanic or Latino

Non-Hispanic or Latino

Decline

Don’t know

What language do you feel most comfortable using when discussing your healthcare?

English

Spanish

German

French

Italian

Russian

Portuguese

Chinese

Other

Decline

Don’t know

How often do you use internet for gathering information?

Always

Usually

Sometimes

Never

Medical History Forms

Cancer diagnosis or reason for consultation:

Past Medical History

Please check all that apply:

Allergies

COPD

High blood pressure

Anxiety

Depression

Inflammatory Bowel Disease (Crohn’s disease, colitis, etc)

Anemia/Blood Disorder

Diabetes

Migraines/headaches

Arthritis

Diverticulitis

Neuropathy

Asthma

Erectile dysfunction

Psychosis

Atrial fibrillation/irregular heartbeat

Fibromyalgia

Rheumatoid Arthritis

Autoimmune disorder (lupus, scleroderma, RA, etc)

GERD

Seizures

Bipolar Disorder

Gout

Stroke

Blood clots or pulmonary embolism

Heart Attack

Thyroid Disorder

BPH (prostate)

Heart Disease

Tremors

CAD (coronary artery disease)

High cholesterol

Osteoporosis

Cancer, prior history:

Infectious disease (HIV, hepatitis, Tuberculosis, etc)?

Other

Have you ever received radiation therapy?

Yes

If yes, when?

MM slash DD slash YYYY

Radiation Therapy Physician’s Name/Facility

Radiation Therapy Facility Address

What area was treated?

Have you ever received chemotherapy?

Yes

If yes, when?

MM slash DD slash YYYY

Chemotherapy Physician’s Name/Facility

Chemotherapy Therapy Address

Past Surgeries

Please list surgery, year of operation, surgeon and location (if known). Click the "PLUS" symbol to add more rows.

Procedure/Operation

Date

Physician

Location

Do you have any implanted medical devices such as a PACEMAKER, DEFIBRILLATOR, neurostimulator, drug infusion pumps, etc?

Yes

If yes, please provide copy of your medical device card to front desk.

Allergies

Are you allergic to any medications?*

Yes

If yes, medication name/reaction:

Are you allergic to latex?*

Yes

If yes, latex reaction:

Are you allergic to IV Contrast?*

Yes

If yes, IV Contrast reaction:

Others (food, tape, environmental, etc.)

Medications

Pharmacy Name

Pharmacy Number

Pharmacy Address

Street Address

Please list ALL medications. Click the "PLUS" symbol to add more rows.

Medication

Dose

Frequency

Prescribing Physician

Consent to Obtain Patient Medication History

Patient medication history is a list of prescriptions that healthcare providers have prescribed for you. A variety of sources, including pharmacies and health insurers, contribute to the collection of this history.

The collected information is stored in the practice electronic medical record system and becomes part of your personal medical record. Medication history is very important in helping providers treat your symptoms and/or illness properly and avoid potentially dangerous drug interactions.

It is very important that you and your provider discuss all your medications in order to ensure that your recorded medication history is 100% accurate. Some pharmacies do not make prescription history information available, and your medication history might not include drugs purchased without using your health insurance.

Also, over‐the‐counter drugs, supplements, or herbal remedies that you take on your own may not be included.

Consent*

I give my permission to allow my healthcare provider to obtain my medication history from my pharmacy, my health plans, and my other healthcare providers. Valid for 1 year from date of signature.

Patient Name:*

Today's Date:*

MM slash DD slash YYYY

Family History

Father: if living, age

Father: If deceased, age at death

Father Medical Problems

Mother: if living, age

Mother: if deceased, age at death

Mother Medical Problems

Siblings: # of Females

Siblings: # of Males

Siblings: Medical Problems/Deceased

Children: # of Females

Children: # of Males

Children: Medical Problems/Deceased

Social History

Marital Status:

Single

Married

Divorced

Widowed

Separated

Spouse or significant other’s name

Social Geographic History

Where were you born?

Where did you live most of your life?

Do you live in this state all year round?

Yes

Please provide your alternate address:

Street Address City State ZIP Code

Occupation/Service History

Occupation

Are you:

Retired

Disabled

Reason for disability?

Have you served in the military?

Yes

To your knowledge, have you ever worked in an occupation that involved exposure to asbestos or other cancerous chemicals, fumes, or carcinogens?

Yes

If yes, describe:

Substance History

Have you ever smoked?

Yes

If yes, what?

Cigarettes

Cigars

Pipe

How many years smoking?

Please enter a number from 1 to 99.

Packs/number per day?

Please enter a number from 1 to 99.

If yes, have you quit smoking?

Yes

If yes, when did you quit smoking?

MM slash DD slash YYYY

Have you ever chewed tobacco?

Yes

How much?

If yes, have you quit chewing tobacco?

Yes

If yes, when did you quit chewing tobacco?

MM slash DD slash YYYY

Do you drink alcoholic beverages?

Yes

If yes, how often and how much do you drink?

If yes, have you quit drinking alcohol?

Yes

If yes, when did you quit drinking alcohol?

MM slash DD slash YYYY

Have you or do you use street drugs?

Yes

If yes, describe:

Preventative Health Maintenance

(Female) Last mammogram:

(Female) Last pap smear:

(Female) Last colonoscopy:

(Female) Last bone density scan:

(Female) Last pneumonia vaccine:

(Female) Last influenza (flu) shot:

(Male) Last PSA screening:

(Male) Last prostate exam:

(Male) Last colonoscopy:

(Male) Last bone density scan:

(Male) Last pneumonia vaccine:

(Male) Last influenza (flu) shot:

Mobility Risk Assessment

Do you need assistance walking?

Yes

Have you fallen before or been injured because of a fall?

Yes

Do you use a

cane?

walker?

wheel chair?

Do you feel weaker than you used to or have less strength in your arms or legs?

Yes

Have you stopped or avoided exercise/daily activities because of a fear of falling?

Yes

Do you have foot ulcers, bunions, hammertoes, or calluses that hurt or cause you to adjust your steps?

Yes

Do you feel dizzy when you stand up?

Yes

How many falls have you had in the last 12 months?

Did you suffer an injury from you falls?

Yes

Please explain:

Females Only

Age at first menstrual period:

Do you still have periods?

Yes

Date or age of last menstrual period:

Age at first pregnancy:

Number of pregnancies:

Number of births:

Did you breastfeed?

Yes

Have you ever taken hormone replacement therapy?

Yes

If yes, how many years?

Pain Assessment

Do you have pain now?

Yes

Where is your pain located?

On a scale of 1-10, with 1 being very mild and 10 being the worst pain imaginable, what number is your pain?

How would you describe the pain? (e.g. aching, stabbing, burning, throbbing, sharp, dull)

When did your pain start?

Does anything make it better or worse?

Are you taking pain medications?

Yes

If so, what pain medication?

Review of Systems

Have you recently experienced any of these symptoms? Please select all that apply

General

Fever/Chills

Fatigue

Weight loss/gain

Eyes and Vision

Glasses/contacts

Eye disease or injury

Eye pain or pressure

Blurred or Double vision

Ears, Nose, Throat

Hearing loss

Ringing in ears

Ear ache or drainage

Sinus problems

Nose bleeds

Dental problems

Dentures

Mouth sores

Sore throat

Difficulty/painful swallowing

Hoarseness or voice change

Swollen glands in neck

Heart/Cardiovascular

Chest pain

Heart Palpitations

Dizziness

Swollen legs/ankles

Respiratory

Frequent Coughing

Spitting up blood

Wheezing or asthma

Shortness of breath

Endocrine

Loss of hair/thinning hair

Heat/cold intolerance

Excessive thirst

Gastrointestinal

Loss of appetite

Nausea or Vomiting

Stomach pain

Frequent diarrhea

Constipation

Blood in stool

Genitourinary

Frequent urination

Burning or painful urination

Blood in urine

Incontinence or dribbling

Urgency

Vaginal discharge

Painful/irregular periods

Sexual difficulty

Psychiatric

Depression

Anxiety/Nervousness

Sleep Disorders

Suicidal Thoughts

Hematology/Lymphatic

Easily bruise or bleed

Anemia

Slow to heal

History of transfusion

Musculoskeletal

Joint pain or stiffness

Back pain

Muscle pain or cramps

Cold arms or legs

Difficulty walking

Skin and Breast

Rash or Itching

Lesion or change in skin color

Breast mass/lump

Nipple discharge / retraction

Open or non-healing wound

Neurological

Frequent headache

Lightheaded or dizzy

Confusion

Speech difficulty

Seizure activity

Numbness or tingling

Weakness in arms or legs

Depression Screening

Over the last 2 weeks, how often have you been bothered by any of the following problems?

1. Little interest or pleasure in doing things

Not at all

Several days

More than half the days

Nearly every day

2. Feeling down, depressed, or hopeless

Not at all

Several days

More than half the days

Nearly every day

3. Trouble falling or staying asleep, or sleeping too much

Not at all

Several days

More than half the days

Nearly every day

4. Feeling tired or having little energy

Not at all

Several days

More than half the days

Nearly every day

5. Poor appetite or overeating

Not at all

Several days

More than half the days

Nearly every day

6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down

Not at all

Several days

More than half the days

Nearly every day

7. Trouble concentrating on things, such as reading the newspaper or watching television

Not at all

Several days

More than half the days

Nearly every day

8. Moving or speaking o slowly that other people could have noticed? Or the oppoite - being o fidgety or restless that you have been moving around a lot more than usual

Not at all

Several days

More than half the days

Nearly every day

9. Thought that you would be better off dead or of hurting yourself in some way

Not at all

Several days

More than half the days

Nearly every day

Advance Directives

Do you have a medical power of attorney?

Yes

Do you have an advance directive?

Yes

Do you have a living will?

Yes

Do you have a donor card?

Yes

Please provide a copy of the document:

Max. file size: 128 MB.

Please list the names and addresses of Physicians you would like correspondence sent to:

Physician name and phone

As the patient you acknowledge with the completion of this form it constitutes your complete clinical history summary

By entering my name I agree that the signature and initials will be the electronic representation of my signature and initials for all purposes when I use them in this form - just the same as a pen-and-paper signature or initial

Patient / Responsible Party Signature*

Date*

MM slash DD slash YYYY

Do you agree to sign electronically?*

Yes, I agree to sign electronically.

Nurse Signature

Date

MM slash DD slash YYYY

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Consent

Yes, I agree to sign electronically.

Physician Signature

Date

MM slash DD slash YYYY

This field is hidden when viewing the form

Consent

Yes, I agree to sign electronically.

GENERAL CONSENT FOR TREATMENT, FINANCIAL AGREEMENT, AND COMMUNICATION AUTHORIZATION

Precision Healthcare Specialists, LLC

We are pleased to share that we are now part of Precision Healthcare Specialists. This transition allows us to expand our resources and continue strengthening the care we provide to our patients and community.

What this means for you:

Your care will not change. You will continue to see the same physicians and care team you know and trust.
Your treatment and services remain the same. There is no change to the quality or approach to your care.
Billing statements and other administrative forms may reflect a new name. You may see Precision Healthcare Specialists listed on billing and related communications.

If you have any questions about this update or your account, please contact our office. We are happy to assist you. Thank you for trusting us with your care.

Consent for Medical Evaluation and Treatment

I voluntarily consent to receive medical evaluation, diagnostic procedures, and treatment from Precision Healthcare Specialists (“the Practice”), including its physicians, advanced practice providers, nurses, technicians, students, trainees, and other healthcare personnel involved in my care.

My care may include:

Medical evaluation and examination
Diagnostic testing and procedures
Laboratory testing and imaging
Administration of medications
Routine medical treatment and care
Telehealth services when appropriate

I understand that medications, injections, infusions, or other therapeutic treatments may be prescribed or administered as part of my care. These treatments may involve potential risks or side effects, including but not limited to allergic reactions, medication side effects, infection, bleeding, or other complications. When clinically appropriate, my healthcare provider may discuss the purpose, risks, benefits, and alternatives to these treatments, and I have the opportunity to ask questions before proceeding.

My healthcare provider may discuss with me the nature and purpose of proposed treatments, the material risks and benefits, and reasonable alternatives, including the option of no treatment, when clinically appropriate. I have the right to ask questions about my condition, proposed treatment, risks, benefits, and alternatives, and I have the right to refuse treatment to the extent permitted by law. I understand that refusal of recommended care may affect my health outcomes.

I am responsible for informing my healthcare provider of my medical history, medications, allergies, and any changes in my condition.

Care Team Participation and Coordination of Care

I understand that individuals involved in my care may include physicians, advanced practice providers, nurses, medical assistants, technicians, trainees, students, or other authorized healthcare personnel working under appropriate supervision.

I authorize the Practice to use and disclose my medical information as necessary for treatment, payment, and healthcare operations, including coordination with other healthcare providers involved in my care, consistent with applicable federal and state privacy laws.

Photography and Documentation for Treatment Purposes

I understand that photographs, video, or other recordings may be taken for purposes of diagnosis, treatment, medical documentation, quality improvement, or healthcare operations. These images will be handled in accordance with privacy and security standards and applicable law.

Use of Technology and AI-Assisted Documentation

The Practice may use technology to support high-quality patient care and accurate medical documentation, including voice recognition, ambient listening tools, and artificial intelligence (AI)–assisted documentation systems.

Telehealth services and other electronic technologies rely on communication systems that may occasionally experience interruptions, delays, or technical failures that could require rescheduling or an in-person visit.

I understand that:

Technology may be used during my visit to assist with documentation.
Conversations may be electronically processed to create medical records.
My healthcare provider reviews and approves all documentation entered into my medical record.
These tools support clinical documentation and do not replace medical judgment.
Information collected is handled in accordance with applicable privacy and security laws.

I understand that I may request that these technologies not be used during my visit and that my care will not be affected if I decline.

Consent to use of AI or technology-assisted documentation*

I agree to the use of AI or technology-assisted documentation during my visits.

I decline the use of AI or technology-assisted documentation during my visits.

Procedural Acknowledgment

I understand that certain procedures, treatments, or interventions may involve additional risks and may require separate informed consent documents. When applicable, these procedures will be explained to me, including risks, benefits, and alternatives, and I will have the opportunity to ask questions before agreeing to proceed.

Financial Responsibility

I understand and agree that:

All professional services rendered are the responsibility of the patient or designated party.
Payment is due at the time services are rendered unless other arrangements have been made in advance.
I am responsible for any balance not paid by my insurance carrier, including copayments, coinsurance, deductibles, non-covered services, and denied claims.
Verification of insurance benefits is not a guarantee of payment. Coverage is determined by my insurance plan.
I agree to provide current and accurate insurance information and notify the Practice of any changes.
If my account becomes delinquent, it may be referred for collection, and I may be responsible for reasonable collection costs, attorney fees, and court costs where permitted by law.

Assignment of Benefits

I hereby assign and authorize direct payment of all medical and surgical benefits, including major medical benefits, to Precision Healthcare Specialists for services rendered to me or my dependents.

I authorize my insurance carrier(s), including Medicare, private insurance, and any other health or medical plan, to issue payment directly to Precision Healthcare Specialists. I understand that I remain financially responsible for any amount not covered by insurance.

A photocopy or electronic copy of this authorization shall be considered as valid as the original.

Authorization to Release Information for Payment

I authorize the Practice to release information necessary to:

Process insurance claims
Obtain payment
Coordinate benefits with payers

This authorization remains in effect until revoked by me in writing.

Communication Authorization and Consent to Contact

I authorize Precision Healthcare Specialists, its employees, agents, contractors, and affiliates to contact me using the contact information I have provided regarding my healthcare, appointments, treatment, billing, office policies, updates or changes and related services.

Communication methods may include:

Telephone calls
Text messages (SMS)
Voicemail messages
Email
Patient portal messaging
Automated or prerecorded voice messages
Other electronic communication methods

These communications may include appointment reminders, care coordination, test results, billing matters, practice updates, health education, and information about services that may be relevant to my care.

I understand that:

Calls or messages may be sent using automated dialing systems or prerecorded messages.
Messages may be left on voicemail or with another person unless I notify the Practice otherwise.
Standard message and data rates may apply depending on my mobile carrier plan.
I may opt out of certain communications at any time by notifying the Practice or following opt-out instructions (such as replying STOP to text messages).

Signing this authorization is voluntary. My treatment will not be conditioned upon providing consent to receive communications.

Consent to receive electronic communications*

I agree to receive electronic communications

I decline to receive electronic communications

Consent to Contact for Marketing & Communications

By providing my contact information, I consent to receive communications from Precision Healthcare Specialists and its affiliated providers, which may include appointment reminders, follow-up care information, educational content, and information about services, programs, or events that may be of interest to me.

These communications may be delivered via phone call, voicemail, text message (SMS), or email, using the contact information I have provided.

I understand that:

Consent to receive marketing or promotional communications is voluntary and is not a condition of receiving treatment or services
Message and data rates may apply for text messages
I may opt out at any time by following the unsubscribe instructions included in communications or by contacting the practice directly

Consent to receive marketing communications*

I agree to receive marketing communications

I decline to receive marketing communications

Advance Directives

I understand that I have the right under Florida law to make decisions regarding my medical care, including the right to accept or refuse treatment and the right to formulate advance directives. Information regarding advance directives is available to me upon request.

Duration of Consent

This consent and authorization will remain in effect for the duration of my treatment with Precision Healthcare Specialists unless revoked by me in writing.

Patient Acknowledgment and Signature

I have read and understand this document. I have had the opportunity to ask questions about my care, and my questions have been answered to my satisfaction. I voluntarily consent to medical evaluation and treatment and agree to the financial and communication terms described above.

Patient / Responsible Party Signature*

Relationship to Patient

Date*

MM slash DD slash YYYY

Consent to sign electronically.*

I agree to sign electronically.*

Witness

Date

MM slash DD slash YYYY

Consent to sign electronically.

I agree to sign electronically.

Medical Records Release Form

Patient Name

Date of Birth

Phone

Address

Street Address City State / Province / Region ZIP / Postal Code

1. I authorize the use or disclosure of the above-named individual’s health information as described below:

2. The following individual or organization is authorized to make the disclosure:

Name

Address

Street Address City State / Province / Region ZIP / Postal Code

3. The type and amount of information to be used or disclosed is as follows: (include dates where appropriate).

All medical records

Consultation Reports

Dosimetry / Physics

Lab results/X‐ray reports

Progress Notes

Follow up

Other (Please specify)

4. I understand that the information in my health records may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse.

5. This information may be disclosed to and used by the following individual or organization.

Location | Advocate Radiation Oncology LLC*

Port Charlotte
3080 Harbor Blvd.
Port Charlotte, FL 33952
Phone: (941) 883-2199
Fax: (941) 979-5041

Port Charlotte 2
3175 Harbor Blvd
Port Charlotte, FL 33952
Phone: (941) 220-6460
Fax: (941) 220-5284

Fort Myers
15681 New Hampshire Ct.
Fort Myers, FL 33908
Phone: (239) 437-1977
Fax: (239) 437-1889

Cape Coral
909 Del Pra do Blvd. S
Cape Coral, FL 33990
Phone: (239) 217-8070
Fax: (239) 217-8069

Bonita Springs
25243 Elementary Way
Bonita Spings, FL 34135
Phone: (239) 317-2772
Fax: (239) 676-7637

Naples
1775 Davis Blvd.
Naples, FL 34102
Phone: (239) 372-2838

Bradenton
5325 E St Road 64
Bradenton, FL 34208
Phone: (941) 220-6263
Fax: (386) 490-9100

Tamarac
7850 N. University Drive
Tamarac, FL 33321
Phone: (754) 205-0099
Fax: (954) 388-5849

West Palm Beach
4832 Okeechobee Blvd
West Palm Beach, FL 33417
Phone: (561) 277-0786
Fax: (561) 277-0831

Wellen Park - Venice
8020 S Tamiami Trail Suite 101
Venice, FL 34293
Phone: (941) 220-6460
Fax: (941) 220-5284

Proton Center
9961 Estero Oaks Dr, 1st Floor
Fort Myers, FL 33967

Lakewood Ranch
8946 77th Terrace East
Lakewood Ranch, FL, 34202-6421

For the purpose of:

6. I understand that I have a right to revoke this authorization at any time. I understand that is I revoke this authorization I must do so in writing and present my written revocation to the health information management department. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. UNLESS OTHERWISE REVOKED, THIS AUTHORIZATION WILL EXPIRE ON THE FOLLOWING DATE, EVENT, OR CONDITION:

7. If I fail to specify an expiration date, event or condition, this authorization will expire in one year. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact a clinic representative at any of the Advocate Radiation Oncology locations.

Consent*

Yes, I agree to sign electronically.

Signature of patient or legal representative*

Date*

MM slash DD slash YYYY

Printed name of Patient or Representative & relationship to patient*

Please carefully review your submission. If there are any errors, use the links above to edit that section.

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