Lung Conference - Tumor Board Case Request | Good Samaritan Medical Center

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Good Samaritan Medical Center

Good Samaritan Medical Center
Cancer Centers of Colorado
340 Exempla Circle, 1st Floor
Lafayette, CO 80026-3384

Call 303-673-1944

All fields are critical – incomplete forms will be returned.

Date Case to be Presented:

Presenting For:

Patient Name:

Patient DOB:mm/dd/yyyy

Patient Age:

Patient Gender:

Medical Record #:

Diagnosis/Site:

Presentation Objective Plan of Care:

Clinical Stage:

Medical Imaging - Only Listed Records Will Be Submitted

If left blank, only 2 most recent SCL images will be presented at conference.
Submissions after deadline will result in imaging commentary only and no images at conference.

Medical Imaging Facility:

Medical Imaging Type:

Medical Imaging Date:

Medical Imaging Facility 2:

Medical Imaging Type 2:

Medical Imaging Date: 2:

Medical Imaging Facility 3:

Medical Imaging Type 3:

Medical Imaging Date 3:

Pathology

If left blank, only the 2 most recent pathology results available in SCL Health Records will be presented at conference.
Pathology reports from non-SCL facilities must be faxed to Elina at 303-403-3550.
Submissions after deadline will result in pathologist commentary only and no images at conference.

Is pathology review critical to this case presentation?

Yes

Pathology Facility:

Pathology Type/Number:

Pathology Date:

Pathology Facility 2:

Pathology Type/Number 2:

Pathology Date 2:

Pathology Facility 3:

Pathology Type/Number 3:

Pathology Date 3:

Physician Presenting Case

Name:

Phone:

Alternate Office Contact

Name:

Phone:

Submissions deadline: Thursday by 11 a.m. the week before conference.

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