Patient Intake Form – PSMA Thank you for your interest in our PSMA treatment for advanced prostate cancer. We want to help you find out if PSMA is the right treatment for you. Please complete our patient intake form so we can learn more about your healthcare journey.To receive the PSMA treatment under current guidelines, patients will need to have been treated with androgen receptor (AR) pathway inhibition, along with at least one taxane-based chemotherapy treatment.We encourage all prostate cancer patients to complete this form as we have alternative treatments available, and the clinical guidelines for PSMA may change as further research emerges. We would like to remain in communication to keep you updated.Patient InformationName(Required) First Last Email(Required) Phone(Required)Medical InformationHave you been treated with androgen receptor (AR) pathway inhibition?(Required) Yes No Have you been treated with taxane-based chemotherapy?(Required) Yes No Please add any additional comments that are relevant to your case.Date of birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance informationNote to patients: Self-pay for the full PSMA (Pluvicto) treatment may exceed $400,000.Will you be seeking insurance coverage for PSMA or will you be self-pay?(Required) Insurance Self-pay Note to patients: Self-pay for the full Lu177 PSMA treatment exceeds $400,000 for six treatments. Most insurance, including Medicare, covers PSMA.Insurance provider(Required) Insurance group number(Required) Member ID(Required) Physician InformationPlease note – a physician’s referral is required to start the consultation process for Pluvicto treatment. If you do not have a referral from your physician and are qualified through this questionnaire for a treatment consultation, we will fax a request for referral to your physician.Has your physician referred you to ARA for a Pluvicto consultation?(Required) Yes No Referring physician name First and last name Referring physician specialty (ex. oncologist; urologist)Referring physician practice name Referring physician address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Referring physician phoneReferring physician faxPlease add any additional comments that are relevant to your case.
