New Patient Form

Your Cancer Care Journey Begins Here

We recognize the stress and challenges that even thinking about a cancer diagnosis can bring. By filling in the form, we get you ready for your first appointment without wasting time.

New Patient Form

An overview form for all types of treatments and services including an initial consultation, a second opinion or specific treatment options. We realize some of the information is sensitive. This form is only reviewed to direct it to the correct department and to schedule your first appointment.

Please select the area of treatment you are interested in so we can direct your form to the appropriate department.

About The Patient

Patient Name(Required)
I give El Portal Comprehensive Cancer Centers permission to email me at this email address. I understand no medical history or information will be disclosed.I understand no medical history/information will be disclosed.*(Required)
MM slash DD slash YYYY
Sex/Gender(Required)

Are you a dependent?(Required)
Marital Status(Required)

Emergency Contact(Required)
May we speak to this person regarding your care?(Required)

Doctors | Pharmacy

If you don't know the whole address, just put the street name and city, if you know it.

Health Insurance

Primary Insurance Information

Subscriber First and Last Name(Required)

Secondary Insurance Information

Subscriber First and Last Name

Permissions

If there are any medical forms that need to be filled out by El Portal Comprehensive Cancer Center staff there will be a charge of $20.00-$50.00 depending on the type of medical forms.(Required)
There will be a $25.00 charge for all No Show and same day cancelation appointments: We require a 24 hour notice for all cancelation(Required)
I have received a copy of Comprehensive Cancer Center’s Notice of Privacy Practices(Required)
I hereby authorize El Portal Comprehensive Cancer Center to furnish my insurance company with all information that they might request concerning my illness or injury. I hereby assign all Payments to El Portal Comprehensive Cancer Center and affiliates to which I am entitled and responsible El Portal Comprehensive Cancer Center for all charges covered by this assignment. All charges not covered by this assignment and all charges not covered by the insurance company will be my responsibility.
Clear Signature
MM slash DD slash YYYY

If patient is in a nursing facility or rehabilitation facility

All patients coming to be seen at our office will need prior Authorization prior to any visits from the Facility which the patient is staying in.
MM slash DD slash YYYY
Address(Required)
Your privacy is important to us. It is El Portal Comprehensive Cancer Centers’ privacy policy to respect your privacy regarding any information we may collect from you across our website – www.elportalcancercenters.com, in-person and other sites we own and operate. We only ask for personal information when we truly need it to provide a service for you. We collect it by fair and lawful means, with your knowledge and consent. We also let you know why we’re collecting it and how it will be used. We only retain collected information for as long as necessary to provide you with your requested service. What data we store, we’ll protect within commercially acceptable means to prevent loss and theft, as well as unauthorized access, disclosure, copying, use or modification. We don’t share any personally identifying information publicly or with third-parties, except when required to by law. Our website may link to external sites that are not operated by us. Please be aware that we have no control over the content and practices of these sites, and cannot accept responsibility or liability for their respective privacy policies. You are free to refuse our request for your personal information, with the understanding that we may be unable to provide you with some of your desired services. Your continued use of our website will be regarded as acceptance of our practices around privacy and personal information. If you have any questions about how we handle user data and personal information, feel free to contact us. If you have any questions or concerns about our use of your Personal Information (defined below), please do not hesitate to contact us through any of the methods below. Email: manager@elportalcancercenters.com Mail: 3303 M Street, Merced CA 9534 Our complete Privacy Policy is available upon request. The above is a condensed overview of our Privacy Policy.
I have read and understand the Privacy Policy(Required)
El Portal Comprehensive Cancer Centers is committed to protecting and respecting your privacy, and we will only use your personal information to administer your account and to provide the products and services you requested from us. From time to time, we would like to contact you about our products and services, as well as other content that may be of interest to you. If you consent to us contacting you for this purpose, please check the box below to say how you would like us to contact you: You can unsubscribe from these communications at any time. For more information on how to unsubscribe, our privacy practices, and how we are committed to protecting and respecting your privacy, please review our Privacy Policy. By clicking submit below, you consent to allow El Portal Cancer Centers to maintain and process the personal information submitted above to provide you the service requested.
We understand how difficult all of this can be. We are dedicated to delivering the highest quality of service, while providing care and compassion to our patients and their families and caregivers. Please verify that all the required fields are filled in and click the SUBMIT button.

Whether we're your first exam or your second consult...

At El Portal Comprehensive Cancer Centers, we are here to support you in every step of your journey. We want you to feel empowered, informed, and assured in your care. Please reach out to us if you have any questions or wish to schedule a second opinion appointment—we are here for you.

“This is what you’re going through, not who you are.”
— Words of Encouragement