Golden State Cancer Radiation Center Golden State Cancer Centers Woodland Hills West Hills Location Contact Golden State Cancer Radiation Centers
Golden State Cancer Centers - Cancer Radiation Therapy & Treatment | Serving West Hills - Woodland Hills - Los Angeles & Ventura County

818-449-2700
21300 Erwin Street
Woodland Hills, CA 91367
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  • Caring Cancer Radiation Oncology Center

    People who care, treatment that works

  • State-Of-The-Art Cancer Radiation Treatment Center

    Combining State-Of-The-Art technology with the best physicians

  • Advanced Cancer Oncology Radiation Therapy

    Let our team of experts help you to live a healthy life, CANCER FREE

  • Los Angeles Cancer Radiation Treatment Center

    Fighting cancer precisely

  • Successful Cancer Radiation Treatment

    Offering individualized treatment plans, and the highest quality of care to patients

  • Advanced Radiation Cancer Center

    Advanced technolgies, enhanced patient care

  • Comprehensive Cancer Radiation Therapy of Los Angeles

    Providing specialized patient services such as: Support Groups & Patient Navigator to be with you every step of the way!


Golden State Cancer Centers


Patient Registration Form

GENERAL INFORMATION

First Name:
Last Name:
Street Adress:
City:
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Zip:
SS Number (optional):
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Marital Status:
Home Phone:
Mobile Phone:
Name of Referring Doctor:
Phone:
Name of Primary Care Doctor:
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Attention: We will use the address above and all phone numbers listed to contact you, mail copy of office visit notes and/or leave messages regarding your care. Please see the Office Manager if you wish to place a restriction on the use of this information for these purposes.
Are You A Patient In A Skilled Nursing Home?
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Are You Employeed?
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Guarantor Name:
Person responsible for payment if other than patient
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PRIMARY INSURANCE INFORMATION
Name of Insurance:
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DOB:
Member ID #:
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Effective Date:
SECONDARY INSURANCE INFORMATION
Name of Insurance:
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Effective Date:

SIGNATURE
Signature of Patient or Representative: