Call us to talk to a consultant or a doctor about your condition.
1.800.359.6547 Regular office hours: M-F 9 am-5 pm PST
1.702.581.9120 After hours hot line: 7 am-10 pm PST
If you are interested in admission to Alpha Medical Clinic, please answer the following questions. A patient representative will call you to review your needs and discuss arrangements for admission. The information you provide will allow us to be prepared for, as well as facilitate your needs upon arrival. For a PDF form of this questionnaire, click on Medical Questionnaire.pdf. Name:
Address:
Telephone:
Diagnosis:
Treatment to date:
Radiation? Yes/No Dates:
Chemotherapy? Yes/No Dates:
Surgery? Yes/No Dates:
Metastasized? Yes/No Where?
Medications currently taking
Name: Milligrams How many per day?
Name:___________________________Milligrams________How Many per day?______
Are you ambulatory (able to walk)?
Are you eating? How is your appetite? Good/Fair/Poor
Special dietary needs:
Do you require assistance in eating, bathing, and/or using bathroom facilities?
Please explain:
Will a family member accompany you?
Can they assist where needed?
Is there anything else you think we should know to accommodate your needs during your treatment period:
When would you like to arrive?
You may fax your completed questionnaire to 619-427-3008. You may also mail it to: Sunray Marketing Group, 1229 Third Avenue, Suite D, Chula Vista, CA 91911.
If you have questions or need assistance please use use the form below.