CANCER TREATMENT CONSULTATION – GET A SECOND OPINION

Free Cancer Treatment Consultation

Staten Island Radiation Oncology

Preparing for the consultation

For your cancer treatment consultation write down all the questions you might like to ask. It’s very easy to forget what you may want to ask because you may have to absorb a lot of information in a short time. Our doctors are committed to making sure all of your questions and concerns are addressed!

Please fill out the form below and we will contact you to schedule your consultation.

We respect your privacy therefore your information will not be shared, sold, rented or exchanged with anyone.

Consult

Name *

Full Name

Email *

Phone *

Recent Diagnosis *

Date of Diagnosis *

Best Contact Method

Email

Phone

Additional Questions/Comments *

DISCLAIMER *

Yes, I have read disclaimer & agree

DISCLAIMER: Messages that you send to us by e-mail may not be secure. If you choose to send any confidential information to us via e-mail, you accept the risk that a third party may intercept and use this information. If this is of an urgent nature concerning your health, please contact your primary care physician, go to the local emergency room, or call 911. While we cannot diagnose or treat via e-mail, we can provide information and help schedule an appointment if necessary. I give Staten Island Radiation Oncology permission to communicate medical information with me via email:

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