CANCER CENTER FOR HEALING MEDICAL QUESTIONNAIRE Please fill out the medical questionnaire below. Once completed, please save and return as an attachment by email to . Once Dana receives the information she will contact you to arrange a consultation with one of our Cancer Team Doctors. After the consult we will customize a treatment plan. INSURANCE INFORMATION: Please provide Cancer Center For Healing with a front and back copy of your insurance card so we can verify coverage prior to your consultation. NOTE•: In lieu of medical records, please send all pertinent scan reports (MRI, Ultrasounds, PET) and all pertinent labs taken in the last 3 months to We do not accept records on CDs, please provide us with a word or PDF document. Patient Name: Jeffrey Epstein DOB: Jan. 20, 1953 Age: 63 Sex: Male Home Phone: Cell Phone: Who do we contact to set up the consultation (name & hone number): Lesley- Email: Home Address: Street, City, State & Zip 9 East 71s, Street New York, New York 10021 Date of Cancer Diagnosis: Na Type of Cancer (Pathology Diagnosis): N/A 6 Hughes, Suite 12081 Irvine, CAI 92618 www.cancercenterforhealing.com EFTA00295979