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Cancer Patient Physician Report - Non-Hospital Source - Department of Health (New Jersey) Mobile App

Fill in the digital capture fields to specify the patient’s personal information, date of diagnosis, stage information, treatment information, and other data. Designed for physicians operating from a Non-Hospital Source.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Cancer Patient Physician Report - Non-Hospital Source - Department of Health (New Jersey) Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico textbox

    Physician Name

  • Ico multiline

    Street Address

  • Ico textbox

    City

  • Ico textbox

    State

  • Ico integer

    Zip Code

  • Ico integer

    Telephone Number

  • Ico textbox

    Patient Name

  • Ico date

    Date of Birth

  • Ico textbox

    Social Security Number

  • Ico textbox

    Race/Ethnicity

  • Ico textbox

    Marital Status

  • Ico textbox

    Sex

  • Ico multiline

    Patient Address

  • Ico textbox

    City

  • Ico textbox

    State

  • Ico integer

    Zip Code

  • Ico textbox

    Occupation

  • Ico textbox

    Industry

  • Ico multiline

    Primary Site/Laterality of this cancer (attach pathology report):

  • Ico multiline

    Histology Type of this cancer

  • Ico date

    Date this cancer was FIRST DIAGNOSED

  • Ico date

    Initial visit for this cancer

  • Ico date

    Most recent visit for this cancer

  • Ico statictext

    STAGE INFORMATION (Please refer to AJCC Cancer Staging Manual.

  • Ico textbox

    Primary Tumor (T)

  • Ico textbox

    Regional Lymph Nodes(N)

  • Ico textbox

    Direct Metastasis (M)

  • Ico textbox

    Stage Group

  • ...and More!

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More Information


  • Creator: Team GoCanvas
  • Language: English
  • Country: United States of America
  • Type: Reports
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