Dear Patient,

Thank you for your interest in The University of Texas M. D. Anderson Cancer Center. The
International Center (IC) will be happy to assist you in securing an appointment.
Please complete the attached forms and fax them to (713) 792-2079. Be sure to include with
the forms the following information:
Typed pathology reports to include the specimen or accession numbers and
the pathologists name and facility address
Typed surgical reports
Typed laboratory reports
Typed radiology (x-ray, CT scans, ultrasound, bone scan, mammograms, and
MRI) reports
Typed medical and treatment history summary prepared by your physician
to include records of chemotherapy and radiation treatments
Copy of the passport showing name of patient
Patients are required to travel to M. D. Anderson for our physicians to determine the extent of
disease and make appropriate treatment recommendations. However, in some cases after
reviewing the requested information our physicians may recommend that you not travel to
Houston.
Please be advised that it may take a minimum of 3-5 business days for us to inform you of your
appointment from the time we receive your completed forms and your reports. In the meantime,
if you have any questions, please do not hesitate to call your International Patient Assistant (713)
745-0450. The International Center is happy to assist you with housing and ground transportation
arrangements in Houston, as well as provide information that may be helpful as you make your
travel arrangements. Should you have any other special needs or requests please let us know.
Sincerely,
Cynthia Gonzalez
International Patient Assistant
713-745-0450

Please answer all of the following questions. It may be helpful for you to have your
physician assist you in answering these questions. Please type or print clearly.
Todays Date:

PATIENT INFORMATION

___________________________

Patient's name: (first)___________________________________ (last)___________________________________

Date of birth (D/M/Yr): ________________________________ Sex: ____________________________________
Birth City/State/Province: ___________________________________Birth Country: ________________________
Diagnosis: __________________________________________________________________________
Date of diagnosis ___________________ Is this an original diagnosis or a recurrence? ______________________
If this is a recurrence, what is the date of the original diagnosis? ________________________________________
How was the disease diagnosed? Surgical Biopsy _______ Fine Needle Aspiration _____ Resection __________
Has the disease spread to other organs?

Yes ________ No ____________

If yes, please specify where ________________________ and the date it was discovered_________________
Is the patient ambulatory more than 50% of the day?

Yes ______

No ______

Is the patient able to take care of self without assistance?

Yes ______

No ______

Does the patient require the use of oxygen?

Yes ______

No ______

Is the patient jaundiced (skin and/or eyes yellow)?

Yes ______

No ______

Does the patient have ascites (liquid abdominal cavity/swollen)?

Yes ______

No ______

Does the patient have difficulty eating?

Yes ______

No ______

Has the patient had surgery related to above-mentioned diagnosis?

Yes _______

No ______

If yes, please give surgery date and type of procedure ___________________________________________

Has the patient received Chemotherapy?

Yes ______

No ______

If yes, please list specific chemo agents and doses______________________________________________

What is the date of the last treatment? __________________________
When is the next treatment scheduled? _________________________
Has the patient received Radiotherapy?

Yes ______
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No ________

What were the doses and cycles? ___________________________________________________________

What is the date of the last treatment? ______________________________________________________
When is the next treatment scheduled? _________________________
What treatment does the local physician currently recommend? ______________________________________
Has patient suffered from heart problems?

Yes ______

No _______

When was the last MRI or CT Scan? ____________________________________________________________

(Please note: MRI for Neuro patients must have been done within the last 30 days)
What type of service are you requesting from M. D. Anderson (second opinion, evaluation, consultation,
treatment, other)? ____________________________________________________________________________

PATIENT DEMOGRAPHICS / CONTACTS

Marital status: _________________________ Spouses name: ______________________________________
Religious preference: ______________________________Language: _________________________________
Patient's address: ___________________________________________________________________________
City: ___________________________________________State/Province_______________________________
Country: ___________________________________________Zip/Postal code___________________________
Patient's telephone (starting w/country & area code) Home: __________________________________________
Fax: ______________________________________Work: __________________________________________
E-mail: ____________________________________________________________________________________
Contact person(s): Name: _____________________________________________________________________
Relation to patient: _________________________ Home: ____________________________________
Fax: ____________________________________ Cell: _____________________________________
Emergency contact (other than spouse) Name: ____________________________________________________
Relation to patient: __________________________Home: __________________________________
Fax: ____________________________________ Cell: _____________________________________
Do you have insurance?: ______________________________________________________________________
Are you requesting a specific physician at M. D. Anderson?: _________________________________________
If yes, which physician?:_______________________________________________________________
(Please note that requesting a specific physician may delay your appointment)
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Preferred appointment date: ___________________________________________________________________

Do you have a visa? _________________________________________________________________________
Country issuing passport: _____________________________________________________________________

TREATING PHYSICIAN INFORMATION

Please complete the following information about the physician currently treating you. Please type or print clearly.
Physicians Last Name: ______________________________________________________________________
Physicians First Name: ______________________________________________________________________
Physicians Specialty: _______________________________________________________________________
Hospital/Clinic your physician is associated with: _________________________________________________
Physicians Street Address: ___________________________________________________________________
_________________________________________________________________________________________
Cit/State/Province: ________________________________________ Zip Code: _________________________
Country: _______________________________Phone: _____________________________________________
Fax: ___________________________________E-mail: ____________________________________________
Would you like us to keep your physician updated regarding your visit? ________________________________
Was this the physician that referred you to M.D. Anderson? __________. If not, please complete the next section
regarding the physician who referred you.

REFERRING PHYSICIAN INFORMATION

Physicians Last Name: ______________________________________________________________________
Physicians First Name: ______________________________________________________________________
Physicians Specialty: _______________________________________________________________________
Hospital/Clinic your physician is associated with: _________________________________________________
Physicians Street Address: ___________________________________________________________________
__________________________________________________________________________________________
Cit/State/Province: ________________________________________ Zip Code: _________________________
Country: _______________________________Phone: _____________________________________________
Fax: ___________________________________E-mail: _____________________________________________
Would you like us to keep your physician updated regarding your visit? _________________________________

INTERNATIONAL INSURANCE
Name of policyholder: ______________________________________________________________
(as it appears in the insurance policy contract)
Name of patient: ___________________________________________________________________
(as it appears in the insurance policy contract, if the patient is listed as one of the policyholders
dependents, i.e., if the patient is not the policyholder)
Policyholders date of birth (d/m/y): _____________________________________________________
(as it appears in the insurance policy contract, if the policyholder is not the patient)
Name of insurance company: ____________________________________________________________
Telephone number (of the insurance company): _____________________________________________
Fax number (of the insurance company): ___________________________________________________
Policy number: _______________________________________________________________________
Group number: _______________________________________________________________________
Mailing address (for sending insurance claims and account statements):
Street: ______________________________________________________________________________
City: ________________________________________________________________________________
Country: ___________________________________________ Zip code: _________________________
Company where policyholder is employed (this information is necessary only if the insurance coverage is
a benefit provided to the policyholder by his employer):
Company name: ____________________________________________________________________
Address: __________________________________________________________________________
Telephone number: __________________________________________________________________
Policyholders position/title at this company: _____________________________________________
Comments: ___________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________

Please check with your insurance company to see if M. D. Anderson will be able to bill them
directly. If so, please send us a copy of your insurance card (front and back) or a copy of your
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policy if you do not have an insurance card. In most cases, M. D. Anderson can only accept
insurance coverage from insurance companies that have offices within the Unites States.