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Pre-Consultation Checklist (Prostate Cancer) |
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E-mail |
In order for us to best serve you, we request the following materials to be faxed or priority mailed, and/or physically brought into the urology office prior to scheduling the consult appointment. This will allow the physician’s time to review your medical records. These materials will be filed as a part of your medical records at Advanced Urology & Robotic Surgery. If you are going to schedule surgery, we will also need pathology slides. Please arrive 30 minutes early in order to allow sufficient time to complete the registration process.
Pre-Consultation Checklist (Prostate Cancer)
Please print and fill out the following form prior to your office visit. Please Send via Fax/Mail:
Mail: David K. Ornstein, M.D.
733 4th Avenue North
Naples, FL 34102
Fax: (239) 403-9756
_____ Consult history and physical notes from referring physician
_____ Pathology report from biopsy
_____ Ultrasound of prostate, need volume of prostate
_____ Copies of reports from all imaging studies if done, can include a Bone Scan, CT Scan of Abdomen and Pelvis, MRI
_____ History of PSA
_____ Copy of insurance card front and back
_____ Pathology Slides, if done outside of this facility, need to be Fed-Ex’d or hand-carried directly to our office (only if scheduling surgery)
_____ OLD EKG, CHEST X-RAY, Stress Test, Echo, Pulmonary Function Test, etc. (only if scheduling surgery)
_____ Completed history and physical form
Patient Name________________________________________________________________
Patient Signature_____________________________________________________________ Date ________________________
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Pre-Consultation Checklist ( Kidney Cancer ) |
PDF |
| Print | |
E-mail |
In order for us to best serve you, we request the following materials to be faxed or priority mailed, and/or physically brought into the urology office prior to scheduling the consult appointment. This will allow the physician’s time to review your medical records. These materials will be filed as a part of your medical records at Advanced Urology & Robotic Surgery. If you are going to schedule surgery, we will also need pathology slides. Please arrive 30 minutes early in order to allow sufficient time to complete the registration process.
Pre-Consultation Checklist (Kidney Cancer)
Please print and fill out the following form prior to your office visit. Please Send via Fax/Mail:
Mail: David K. Ornstein, M.D.
733 4th Avenue
Naples, FL 34102
Fax: (239) 403-9756
_____ Consult history and physical notes from referring physician
_____ Pathology report from kidney biopsy if available
_____ Disc or hard copy of CT scan or MRI.
_____ Reports of all other imaging studies if done, can include a Bone Scan, CT Scan of Abdomen and Pelvis, MRI
_____ OLD EKG, CHEST X-RAY, Stress Test, Echo, Pulmonary Function Test, etc. (only if scheduling surgery)
_____ Copy of insurance card front and back
_____ Pathology Slides, if done outside of this facility, need to be Fed-Ex’d or hand-carried directly to our office (only if scheduling surgery)
_____ OLD EKG, CHEST X-RAY, Stress Test, Echo, Pulmonary Function Test, etc. (only if scheduling surgery)
_____ Copy of insurance card front and back
_____ Completed history and physical form
Patient Name________________________________________________________________
Patient Signature_____________________________________________________________ Date ________________________
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Pre-Consultation Checklist ( Bladder Cancer ) |
PDF |
| Print | |
E-mail |
In order for us to best serve you, we request the following materials to be faxed or priority mailed, and/or physically brought into the urology office prior to scheduling the consult appointment. This will allow the physician’s time to review your medical records. These materials will be filed as a part of your medical records at Advanced Urology & Robotic Surgery. If you are going to schedule surgery, we will also need pathology slides. Please arrive 30 minutes early in order to allow sufficient time to complete the registration process.
Pre-Consultation Checklist (Bladder Cancer)
Please print and fill out the following form prior to your office visit. Please Send via Fax/Mail:
Mail: David K. Ornstein, M.D.
733 4th Avenue North
Naples, FL 34102
Fax: (239) 403-9756
_____ Consult history and physical notes from referring physician
_____ Pathology report from biopsy
_____ Disc or hard copy of CT scan or MRI.
_____ Reports of all other imaging studies if done, can include a Bone Scan, CT Scan of Abdomen and Pelvis, MRI
_____ History of PSA
_____ Pathology Slides with report, if done outside of this facility, need to be Fed-Ex’d or hand- carried directly to our Department (only if scheduling surgery)
_____ Pathology Slides, if done outside of this facility, need to be Fed-Ex’d or hand-carried directly to our office (only if scheduling surgery)
_____ OLD EKG, CHEST X-RAY, Stress Test, Echo, Pulmonary Function Test, etc. (only if scheduling surgery)
_____ Copy of insurance card front and back
_____ Completed history and physical form
Patient Name________________________________________________________________
Patient Signature_____________________________________________________________ Date ________________________
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