New Patient Arrival Forms
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Welcome to Cancer Treatment Centers of America at Eastern Regional Medical Center. We are pleased you have chosen us to be at the center of your care. In order to make your visit as efficient as possible, please read and fill out the forms outlined below:
Please click on the link(s) below to retrieve your documents. If you would like to speak with someone directly, please contact us at (215) 537-7673 for assistance.
Forms to be returned prior to your arrival
- Hospital and Physician History Form for New Patients
- Authorization for Release of Private Health Information
Forms to be completed and returned during your evaluation
The following forms will help us prepare for your initial evaluation:
- Naturopathic Medicine Informed Consent Form
- Family History Questionnaire
- Patient’s Privacy Code Number
- The Epworth Sleepiness Scale
- Notice of Privacy Practices
- Notice of Privacy Practices Receipt Form
- Travel Itinerary Information
Patient Bill of Rights - This document explains your rights and responsibilities as an equal partner in your care.
Frequently Asked Questions - This document provides answers to commonly asked questions about the initial evaluation and the benefits of our Patient Empowered Care® model.
Travel Tips & Information - Your travel coordinator will arrange the details of your visit to the hospital. This document provides information to help you further prepare for your visit, including tips for traveling with a wheelchair and/or home oxygen therapy.
Travel Procedures - This document gives specific travel information to make the process as simple and seamless as possible. This includes information regarding traveling via airline or train. It also contains general travel information that will be helpful to keep in mind.