Radiation Oncology Simulation Registration Form
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Radiation Oncology Simulation Registration Form
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This radiation oncology simulation registration form streamlines the pre-treatment planning process by gathering critical information before the CT simulation appointment. The form captures details about previous radiation treatments, imaging studies, implanted medical devices, tattoos or permanent markers, and any claustrophobia or positioning concerns that may affect simulation and treatment delivery.
Designed for radiation oncology departments and cancer centers, this form ensures technicians and dosimetrists have complete information for optimal treatment planning. It includes insurance verification for radiation services, consent for simulation imaging, and documentation of referring oncologist details. The form helps prevent scheduling delays by identifying patients who may need sedation, specialized immobilization devices, or additional planning time due to complex anatomy or prior treatments.
What's included
- Cancer diagnosis and staging information
- Prior radiation treatment history with dates and sites
- Implanted devices (pacemaker, defibrillator, ports, prosthetics)
- Previous CT, MRI, and PET scan history
- Claustrophobia and anxiety screening
- Tattoo and permanent marker inventory
- Positioning limitations and mobility issues
- Insurance verification for radiation services
- Referring physician contact information
- Emergency contact details
Who uses this template
- Hospital radiation oncology departments
- Outpatient cancer treatment centers
- Academic medical center radiation facilities
- Freestanding radiation therapy clinics
All form fields
9 fields across 3 pages. Customize any field after signing up.
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