HIFU MX :: International Prostate Cancer Center
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Patient Qualification

Do I qualify for HIFU?

HIFU with the Sonablate® 500 has many proven advantages over traditional treatment modalitites for prostate disease. To find out if you qualify please complete your details below.

Please make sure you provide a good description of your medical history including:

*Recent PSA
*Gleason score
*Prostate size/volume
*Treatment strategy thus far
*any other relevant medical information

or call 1-888-814-0202 to speak with us today to find out if you qualify.

First Name:
Last Name:
Age?
Email:
Phone:
City:
Country:
Please describe your general health:
What has been your treatment strategy to date (ex. watchful waiting, radiation, brachytherapy, radical prostatectomy):

Do you have any of the following?
(please check any that apply)

Allergies? Yes No
A history of cardiac problems? Yes No
Diabetes? Yes No
Have you ever had surgery on your spine/back? Yes No
Current PSA:
Cancer stage:
Gleason score:
Size of Prostate (in grams):
Have you had a:
CT Scan Yes No
Results:
Positive Negative
Bone Scan Yes No
Results:
Positive Negative
MRI Yes No
Results:
Positive Negative

Additional comments and questions:
Enter Code:  

 

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