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: DOB: Age: Sex: Home Phone: Cell Phone: Who do we contact to set up the consultation (name & phone number): Email: Home Address: Street, City, State & Zip Date of Cancer Diagnosis: Type of Cancer (Pathology Diagnosis): 6 Hughes, Suite 120B I Irvine, CA 192618 www.cancercenterforhealing.com EFTA00295983