Minton Lodge Patient Medical Release Form

Patient Information

Name

First

Last

Date of Birth

Gender

Male

Female

OtherOther

Phone

Address

City

State/Province

Zip/Postal

Medical Provider / Oncology Team Member Information

Name

First

Last

Title / Role

Clinic/Hospital Name

Phone

Office Address

City

State/Province

Zip/Postal

Patient Cancer Information

Cancer Type

Current Treatment(s)

Treatment Status

Known Allergies or Medical Concerns

Medical Release

Acknowledgement

I, (Medical provider/Oncology team member), certify that the above-named patient is under my care for the treatment of cancer. The patient is in stable enough condition to reside at the Minton Lodge. I confirm that there are no medical contraindications preventing the patient from staying in a comfortable, supportive environment outside of a hospital setting.

I, (Medical provider/Oncology team member), certify that the above-named patient is under my care for the treatment of cancer. The patient is NOT in stable enough condition to reside at the Minton Lodge.

Additional Notes or Recommendations for the Patient's Stay

Signature

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