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: 212 750 9895 Cell Phone: 212 533 3739 Who do we contact to set up the consultation name & hone number : Lesle Email: Home Address: Street, City, State & Zip 9 East 71g Street New York, New York 10021 Date of Cancer Diagnosis: Type of Cancer (Pathology Diagnosis): 6 Hu es, Suite 120B Irvine, CA 92618 EFTA00588766