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    • Home
    • Doctors
      • Neurosurgeons
        • Frank Culicchia, MD, FAANS
        • Robert Applebaum, MD
        • John Steck, MD, FAANS
        • Alan M. Weems, MD, FACS, FAANS
        • Carl Culicchia, MD
      • Neuro-oncology
      • Neurologists
        • Steven Atkins, MD
        • R. Charles Fiore, Jr., MD
        • K. David Khoobehi, MD
        • Michael Puente, MD
      • Interventional Neuroradiology
        • Robert Dawson, MD
      • Physical Medicine/Pain Management
        • Andrea Toomer, MD
        • Brian Michael Koch, MD
        • Stephen Rynick, MD
      • Hearing and Balance-Neurotology
        • Moises Arriaga, MD
      • Audiologist
        • Elizabeth Montgomery, Au.D., CCC-A, F-AAA
        • Patti St. John, Au.D., CCC-A, F-AAA
        • Brittany Thomas, Au.D., CCC-A, F-AAA
      • Nurse Practitioner
        • Danielle Alfortish, APRN, FNP-C
      • Physician Assistant
        • LaShon Maggio, PA-C
      • Physical Therapy
        • Carrie Black, PT, DPT, C/NDT
        • Rebecca Callais, OT, LOTR
    • Specialties
      • Neurosurgery
        • Aneurysm
        • AVM: Microcatheterization
        • Hydrocephalus
      • Neurology
        • Migraines
        • Multiple Sclerosis
        • Parkinson’s Disease
        • Stroke
          • Carotid Artery Screening
          • Survivor: Sarah Abrusley
      • Hearing and Balance-Neurotology
        • Acoustic Neuroma
        • Cochlear Implants
      • Audiology
      • Physical Medicine / Rehabilitation
        • Spasticity
        • Baclofen Pump
        • Botulinum Toxin Injections
      • Physical Therapy
        • Unlocking Spasticity
        • Vestibular Rehabilitation for Inner Ear and Balance
      • Spine
        • Facet Injection
        • Lumbar Steroid Injection for Low Back Pain
          • Epidural Steroid Injection
        • Kyphoplasty
        • Lumbar Laminectomy for Sciatica
        • Mobi-C Cervical Disc Replacement
        • Percutaneous Discectomy
        • Trufuse Facet Procedure
        • Stenosis
          • Superion Vertiflex for Lumbar Spinal Stenosis
      • Trauma
        • Head Injury
      • Brain Tumors
        • Brain Tumor Second Opinion
        • Pilocytic Astrocytoma
        • Malignant Brain Tumors
        • Optune Brain Tumor Therapy
          • Are You a Candidate for Optune Glioblastoma Treatment?
        • Benign Tumor
        • Meningioma
        • Acoustic Neuroma
        • Vascular
    • NeuroNews
    • Videos
    • Locations
    • Pay Bill
    • Careers
    • Patient Portal
    • 504.340.6976
      Call us Today!

    Brain Tumor Second Opinion (Pt. 2)

    Home » Brain Tumor Second Opinion (Pt. 2)

    Second Opinion Medical Imaging Upload - Part 2

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    • Agreement

    • Statement of Financial Responsibility - I understand that I am responsible for payment to Culicchia Neurological Clinic, LLC for this second opinion. I understand that I am ultimately responsible for all medical expenses incurred and agreed to pay all amounts. HIPAA Regulations - I agree that Culicchia Neurological Clinic may request and use my prescription medication history from other healthcare providers or third-party pharmacy benefit payors for purposes of clarification of medical history. The following signature acknowledges that I have received notification of my privacy rights concerning the use and disclosure of protected health information as defined by the privacy regulations.
    • MM slash DD slash YYYY
    • Neuro-Oncology Review of Systems

    • What were the last dates that you had chemotherapy?
    • MM slash DD slash YYYY
    • MM slash DD slash YYYY
    • Review of Systems (1 of 2)

      Please place a check in front of (or circle) any of the following symptoms that you had in the months leading up to your first visit with us, or that you’ve had in the time since we’ve last seen you. If you have not had any symptoms in the category, please place a check in front of (or circle) “No problems”.
    • Review of Systems (2 of 2)

      Please place a check in front of (or circle) any of the following symptoms that you had in the months leading up to your first visit with us, or that you’ve had in the time since we’ve last seen you. If you have not had any symptoms in the category, please place a check in front of (or circle) “No problems”.
    • Neuro-Oncology Patient History

    • (Including non-prescription medications, over the counter supplements, etc)
      Medication NameDose (mg)Times per dayMonth/Year started taking 
    • Pharmacy Information

    • Gynecological History

      (For Female Patients Only):
    • MM slash DD slash YYYY
    • MM slash DD slash YYYY
    • YearIllness or OperationYearIllness or Operation 
    • Please check any previous and/or current cancers you have been diagnosed with
    • Previous Cancer Treatments

    • (what kind?)
    • (what agents?)
    • (to where?)
    • (specify)
    • (what kind?)
    • (what agents?)
    • (to where?)
    • (specify)
    • (what kind?)
    • (what agents?)
    • (to where?)
    • (specify)
    • Social

    • Tobacco, Alcohol, and Drug Use History

    • Alcohol History

    • Glasses of wineCans/bottles of beerShots of liquorDrinks containing 0.5 oz of alcohol
    • Illicit/Recreational Drug Use History

    • Sexual History

    • Family History

      Have any of your relatives had:
    • Patient Provider Information


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