Histotripsy Interest Form
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Height
*
Weight
*
Are you able to provide your insurance information?
*
Yes
No
Insurance Provider
*
Insurance Primary Subscriber Name
*
First Name
Last Name
Insurance Subscriber ID
*
Primary Cancer Type
*
Hepatocellular Carcinoma
Cholangiocarcinoma
Colon
Rectal
Neuroendocrine
Renal Cell Carcinoma
Breast
Sarcoma
Gastrointestinal Stromal Tumor
Pancreas
Stomach
Lung
Other
Date of Cancer Diagnosis
*
-
Month
-
Day
Year
Date
Site(s) of metastases (areas of the body where cancer is confirmed or suspected)
*
None
Liver
Lung
Bone
Other
What treatments have you received for your cancer?
*
Chemotherapy
Immunotherapy
Surgery
Radiation
Ablation
Y-90
Hepatic Artery Infusion Pump
None
Other
Are you currently undergoing a clinical trial?
*
Yes
No
Please specify
Primary Oncologist Name
*
First Name
Last Name
Suffix
List all facilities where you've received cancer treatment
*
What is your ECOG Performance Status?
*
0 - Fully active, able to carry on all predisease performance without restriction.
1 - Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature.
2 - Ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours.
3 - Capable of only limited self-care; confined to bed or chair more than 50% of waking hours.
4 - Completely disabled; cannot carry on any self-care; totally confined to bed or chair.
Do you have any of the following conditions?
*
Heart Failure
Chronic Lung Disease
Diabetes
Advanced Liver Disease / Cirrhosis
None of the Above
Please upload your latest oncology note
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Please upload your latest abdominal imaging report
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I understand that it is my responsibility as a self-referred patient to inform my primary care team and oncologist of my intention to pursue histotripsy.
*
I understand
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I acknowledge that I am submitting my personal information to NGHS, which will be used in accordance to the NGHS Online Privacy Statement.*
*
I agree
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