Colorado CyberKnife New Patient Information Form

1. Please fill out the form below.

First Name *This question is required.

Middle Initial

Last Name *This question is required.

Date of Birth (mm/dd/yyyy) *This question is required.

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Sex *This question is required.

Street Address

Apt/Suite

City

State

Postal Code

Email Address

Primary Phone *This question is required.

Secondary Phone

Emergency Contact *This question is required.

Phone# *This question is required.

Relationship *This question is required.

If Other:

Name of Referring Doctor

Name of Primary Care Doctor

Type of Cancer

2. Primary Insurance Information - Please fax us copies of your insurance card, front and back, to 303-926-9801 OR fill out the following:

Insurance Carrier

Policyholder Name

Date of Birth

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Policy#

Group#

Customer Service / Provider Phone #

If Other:

Employer Name

Address

City

State

Postal Code

3. Secondary Insurance Information - Please fax us copies of your insurance card, front and back, to 303-926-9801 OR fill out the following:

Insurance Carrier

Policyholder Name

Date of Birth

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SS#

Policy#

Group#

Customer Service / Provider Phone #

If Other:

Employer Name

Address

City

State

Postal Code

4. Communication Information:

Have you contacted Colorado CyberKnife in the past? *This question is required.

Would you like Colorado CyberKnife to contact you? *This question is required.

Patient or Authorized Representative, please let us know which forms of communication you permit Colorado CyberKnife to send you HIPAA / patient protected medical information: *This question is required.

Space Cell	Yes	No
Email Address *This question is required
Primary Phone *This question is required
Secondary Phone *This question is required
Emergency Phone *This question is required
Mobile Phone *This question is required
Work Phone *This question is required
Home Mailing Address *This question is required

Signed and Printed Signatures:

Submission of this form electronically requires the use of a digital signature. The Uniform Electronic Transactions Act, Colo. Rev. Stat. §24-71.3-101, authorizes Creekside Cancer Care, LLC DBA Colorado CyberKnife to accept digital signatures in place of manual signatures. Your digital signature on this form has the same legal effect as your manual signature. By signing this form, you authorize Creekside Cancer Care, LLC DBA Colorado CyberKnife to send you HIPAA compliant information to the email address provided by on this form.

Please type your name:

Please sign your name:

5. Signature Details

If Signed by Authorized Representative with Power of Attorney, Your Relationship to Patient:

Signature Date (mm/dd/yyyy) *This question is required.

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Colorado CyberKnife New Patient Information Form

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