Patient Forms

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Here you will find important forms and quick links to other information on our web site that will help you prepare for your visit at Cancer Care Northwest.

 

Cancer Care Northwest New Patient Forms

Please download and fill out the forms below that relate to you. Bring the completed forms to your first appointment. Not all questions may pertain to you, but we ask that you complete all forms to the best of your ability. This information helps us provide the best possible care based on your current and past general health and any related family history. We encourage new patients to review the necessary forms ahead of time in order to be fully aware their medical background and resources they will be offered as a patient at Cancer Care Northwest. Click on the links to download:

• New Patient Checklist

• New Patient Questionnaire: Please fill out the questionnaire that is most appropriate for your visit:

  • New Patient Questionnaire (*excluding breast patients, who need to complete the New Patient Breast Care Questionnaire provided below)

  • New Patient Breast Care Questionnaire

• Assignment of Benefits Form

• Notice of Privacy Practices Acknowledgement Form (Please complete this form after reading Cancer Care Northwest's Notice of Privacy Practices)

• Patient Contacts Form

• ePrescribe Program Medication History Transaction Form

• Patient Mobility Form 

• Medicare Secondary Payer Screening Form (Medicare Patients Only)

 

PET/CT Forms 

(Intended for patients already schedule for a scan)

• Preparation for Patients Undergoing PET/CT Scans

• Preparation for Patients Undergoing PET/CT BONE Scans

• CT IV Contrast Prep Form  

 

Release of Patient Information Form

• Patient Authorization to Use, Disclose and Release Protected Health Information 

 

Additional Information

• Cancer Glossary

• Mythbusters

 

Quick Links

• Counseling Services and Support Groups
• Nutrition Consultations
• Patient Advocates (Financial Help)
• Patient Navigation
• Yoga