Brain Tumor Second Opinion (Pt. 2) - Culicchia Neurological Clinic

Patient First Name*
Patient Last Name*
Patient Email Address*
File
Max. file size: 50 MB.
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.
Signature*
I agree.
Today's Date
MM slash DD slash YYYY

Neuro-Oncology Review of Systems
Are you currently on chemotherapy?*
- Yes
- No
What were the last dates that you had chemotherapy?
By Mouth:
MM slash DD slash YYYY
By Vein:
MM slash DD slash YYYY
Do you use a medication to thin your blood?*
- Yes
- No
What medication?
Do you take aspirin every day?*
- Yes
- No
Have you had any hospitalizations or visits to the emergency department since your last visit?*
- Yes
- No
What day(s)
What was the reason for your emergency department visit and/or hospitalization?

Patient Provider Information
Family physician:
Name
Specialty
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Fax
Neurosurgeon:
Name
Specialty
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Fax
Radiation Oncologist:
Name
Specialty
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Fax
Medical Oncologist:
Name
Specialty
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Fax
Other

Medication Name	Dose (mg)	Times per day	Month/Year started taking

Year	Illness or Operation	Year	Illness or Operation

Agreement