New Patient Documentation

 
Welcome to Waverly Hematology Oncology (WHO). As a new patient, there are several forms that need to be filled out prior to your first visit to our clinic. The New Patient Documentation PDF is a downloadable PDF file that contains your new patient packet materials.
 
Please fill out this document as completely as possible. Parts of the document can be filled out electronically before printing for final signature. 
 
Within the New Patient Documentation PDF, you will find the following:
 
Page 1) Patient Information - Provide demographic information about yourself.
       
Page 2) Authorization for Release of Information -  Authorization for us to release information to your personal representatives and how best we can contact you.
 
Page 3) Acknowledgement of Receipt of Notice -  Signature sheet confirming you have received our privacy policies and understand our policy about how to handle complaints (See Notice of Privacy Practices, pages 7-9).
 
Page 4) Medical Release of Information - Signature sheet allowing us to retrieve your medical information from your other physicians and health care team.
 
Page 5) Signatures of Patient or Authorized Person - Signature sheet for consents to report a claim and receive treatment.
 
Page 6) New Patient Family History - We are very interested in the nature of your cancer or blood disease. Your first visit will be simpler and quicker if you think about your ancestry before coming to your first visit, especially focusing on any members in your family who have medical issues similar to your hematology or oncology diagnosis.
 
Pages 7-9) Notice of Privacy Practices
 
 

 
Please bring the completed form with you to your first visit.
 
If you have any questions concerning your status as a new patient, please contact our new patient coordinator, Elizabeth Barnard, at our number: (919) 233-8585 or email: ebarnard@waverlyhemeonc.com