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Patient Self-Referral Form
Information about You:
Your name *
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Gender *	Male Female
Date of Birth (MM/DD/YYYY)
Street Address
City/Municipality
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Zip/Postal Code
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Phone (day) *
Phone (evening)
Fax Number
Information about your Primary Care Physician:
Physician Name
Hospital/Clinic Name
City/Municipality
State/Province
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Office Phone
Office Fax
Your Current Treatment Information:
Are you currently under treatment?	Yes No
Current Treatment Clinic
Current Treatment Method	Not Currenlty Under Treatment Chemotherapy Hormone Therapy Radiation Therapy Surgery Other (combinational) None
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Diagnosis Date (MM/DD/YYYY)
Diagnosis Method	Select Method of Diagnosis Biopsy Lab Work CT Scan MRI Ultrasound X-Ray Cytology Other (combinational)
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Your Requested Duke Treatment Information:
Which Duke Clinic Will You Visit?	Select a Clinic Duke Medical Center Durham, North Carolina Durham VA Medical Center Durham, North Carolina Durham Regional Hospital Durham, North Carolina Ravenel Oncology Center, Martinsville, Virgina Maria Parham Hospital, Henderson, North Carolina Granville Medical Center, Oxford, North Carolina Person County Hospital, Roxboro, North Carolina Duke Health Raleigh Hospital, Raleigh, North Carolina Naples Community Hospital, Naples, Florida
Desired Treatment Method	Select Desired Treatment Method Chemotherapy Hormone Therapy Radiation Therapy Surgery Other (combinational)
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Have you ever been to Duke as a patient?	Yes No
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