Home Patients Consultation General Information General Information Name (full name) Gender    /   Age Address (Postal code) () Telephone Mobile E-mail Person Completing this Form   Patient    /   Other Medical Information Cancer Type Prostate cancer Note: If you are not a prostate cancer patient please go to bottom or end of this form and supply medical diagnosis in space provided PSA value Gleason’s Score Stage (if known) Has MRI of Prostate been done?            Yes    /   No If done, what did it show? Organ confined? Pelvic node involvement? Has CT of Abdomen and/or Pelvis(Prostate) been done?            Yes    /   No If done, what did it show? Has Bone scan been done?            Yes    /   No If done, what did it show? Bone metastases? Have you received any treatment for prostate? - Surgery :            Yes    /   No - Radiotherapy :            Yes    /   No - Hormone therapy (Androgen deprivation therapy) :            Yes    /   No Previous cancer history and/or previous radiotherapy history Other medical problems Urinary problems Current medication If you are not a prostate cancer patient, Please give the history of your current problem. It may include symptoms, treatments, pathology reports and when it started. Cancer Type Medical problem Current medication The online submission provides the quickest assessment and accurate treatment quote for you. No matter where you live we provide a professional doctors quote as soon as possible and assist you to proceed for the viable treatment.        ▣ If you are residency in USA and/or Canada you can also download the files then fax to + 1 912 261 0747   or email directly to Curtis Poling, curtis@protonkorea.com. ▣ If you are outside of USA and/or Canada you can also download the files then fax to +82 3496 3255   or email directly to Noah, noah@protonkorea.com Medical Release Form Download - Please click here       │