Oncology Intake Form
Asks about cancer diagnosis & stage, date of diagnosis, and prior cancer treatments. Built for medical oncology and hematology-oncology practices.
- Questions
- 16
- Pages
- 2
- Time
- about 4 min
Includes
- Consent agreement
- File upload
Your practice
Oncology Intake Form
Page 1 of 2 · Your information
Live preview. Tap through it like a patient.
Who it is for
- Medical oncology and hematology-oncology practices
- Radiation oncology and treatment planning centers
- Comprehensive cancer centers and tumor boards
- Cancer survivorship and follow-up care programs
What's inside
Page 1 · Your information
- Full NameText · Required
- Date of BirthDate
- Phone NumberPhone
- Email AddressEmail
- Cancer Diagnosis & StageLong Text
Page 2 · Additional details
- Current Cancer SymptomsLong Text
- Pain AssessmentLong Text
- Genetic Testing HistoryLong Text
- Pathology & Imaging RecordsFile Upload
- Psychosocial Distress ScreenLong Text
From form to a ready patient

01
Make it yours
Reword, reorder, or add to the Oncology Intake Form, and add your logo.

02
Patients finish it at home
A secure link by text or email, filled out on their phone before the visit. No app.

03
Your team sees who is ready
Each visit shows as ready once its forms are in. Answers land on the patient record.
Related templates
All templatesQuestions
Send it before the visit, so patients arrive ready.
Add the Oncology Intake Form to your account and make it yours in a few minutes.
Cancel anytime · BAA included