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  • Patient consultation at Minute Medical private clinic reception, Vienna
    Therapie der Zukunft: we fight your cancer

Patient Intake

Patient Intake Form – MINUTE medical

Initial Medical Data Form

Dear Patient, please fill in this form as completely as possible before your appointment. All information is transmitted securely and treated with strict medical confidentiality. Fields marked ✦ are required.
1

Personal Information

2

Oncological Diagnosis & Clinical Course

Please attach relevant documents

Blood test results (most recent)
Biopsy results
Imaging report (PET/CT, MRI, etc.)
Oncological report
3

History of the Disease

Primary tumor resection
Hormone therapy
Number of cycles
Type / drug name From To
1.
2.
3.
4.
External beam radiation therapy (EBRT)
Number of sessions
Type / details Date
1.
2.
3.
Chemotherapy
Number of cycles
Type / drug name From To
1.
2.
3.
Immunotherapy
Number of cycles
Type / drug name Date
1.
2.
Radionuclide therapy
Number of sessions
Type / details Date
1.
2.
3.
4

Current Medication

5

Additional Information

By submitting this form you consent to MINUTE medical GmbH processing your medical data for the purpose of providing you with medical care, in compliance with the Austrian Data Protection Act (DSG) and GDPR.

Thank you — form received

The MINUTE medical team will review your information and be in touch shortly.
Please do not hesitate to contact us at office@minute-medical.com.