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<div class="VerticalBarCodeMRN"><% =BarCodeMRN %></div>
<div class="VerticalBarCodeDocType">*U16*</div>
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<font style="font-size: 12px;">CONTAINS PROTECTED HEALTH INFORMATION - HANDLE ACCORDING TO MSKCC POLICY</font>
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<td class="FormOuterTableTopRow"><table align="center" border="0" width="650" cellpadding="4" cellspacing="0">
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<td width="325" align="center" valign="middle" class="FormInnerRowRightBorder"><img src="../../Images/FormImages/<%= institutionShortName%>_FormLogo.gif" width="90" alt="" border="0" align="left"><span class="blackBoldText"><%= institutionName%><br>
Urology Upper Tract Urothelial
New Patient</span></td>
<td width="325" align="center" valign="bottom" >
<table width="325" border="0" cellspacing="1" cellpadding="0" >
<tr>
<td width="65"><img src="../../Images/shim.gif" border="0" width="65" height="1"></td>
<td align="left" width="260"><img src="../../Images/shim.gif" border="0" width="260" height="1"></td>
</tr>
<tr>
<td align="right"><% =patientMRNLabel %> </td>
<td align="left"><strong><% =patientMRN %></strong> <% =patientDOB %></td>
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<tr>
<td colspan="1" align="right"><% =patientNameLabel %> </td>
<td colspan="1" align="left"><strong><% =patientLastName %>, <% =patientFirstName %> <% =patientMiddleName %></strong></td>
</tr>
<tr>
<td align="right" valign="top"><% =patientAddressLabel %> </td>
<td align="left" valign="top"><% =patientAddress1 %><% =patientAddress2 %><% =patientCity %> <% =patientState %> <% =patientPostalCode %></td>
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<tr>
<td colspan="2"><img src="../../Images/shim.gif" border="0" width="1" height="5"></td>
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<td colspan="2" align="center" valign="bottom" class="blackBoldText">Patient Identification</td>
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</table></td>
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<td class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="11"><span class="blackBoldText">Date: <% =apptClinicDate %></span></td>
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<td align="center" class="FormOuterTableRow"> <table width="650" border="0" cellspacing="0" cellpadding="4">
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<td width="510" colspan="3"><span class="blackBoldText">Lab Tests</span> Date:
______________ Data Source:_______________</td>
</tr>
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<td colspan="3"><img src="../../Images/standardLabsGridLined.gif" width="642" height="98"></td>
</tr>
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<td class="FormOuterTableRow"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="0">Imaging</span><span><img src="../../Images/shim.gif" border="0" width="12" height="1">
<input type="checkbox" name="Films Reviewed">
Films Reviewed<img src="../../Images/shim.gif" border="0" width="12" height="1">
<input type="checkbox" name="Compared to Past">
Compared to Past<img src="../../Images/shim.gif" border="0" width="12" height="1">
<input type="checkbox" name="Reviewed with Radiologist">
Reviewed with Radiologist<img src="../../Images/shim.gif" border="0" width="12" height="1">
<input type="checkbox" name="Digitized">
Digitized<br>
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<td width="100" align="center" valign="middle" class="FormInsideTableTopCell">Date</td>
<td width="100" align="center" valign="middle" class="FormInsideTableTopCell">Study</td>
<td width="150" align="center" valign="middle" class="FormInsideTableTopCell">Results</td>
<td width="300" align="center" valign="middle" class="FormInsideTableTopCell">Notes</td>
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<td class="FormInsideTableRegCell"> </td>
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<td height="25" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
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<td height="25" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
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<td height="18"> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>--->
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<td align="center" valign="top" class="FormOuterTableRow"><img src="../../Images/KidneysUretersBladder.gif" width="462" height="260" vspace="2"></td>
</tr>
<tr>
<td class="FormOuterTableRow"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="15">Cytology</span><span>
<img src="../../Images/shim.gif" border="0" width="30" height="1">
<input type="checkbox" name="Films Reviewed2">
Reviewed with Pathologist</span><br> <table align="center" border="0" width="650" cellpadding="0" cellspacing="0">
<tr>
<td width="100" align="center" class="FormInsideTableTopLeftCell">Date</td>
<td width="150" align="center" class="FormInsideTableTopCell">Source</td>
<td width="250" align="center" class="FormInsideTableTopCell">Results</td>
<td width="150" align="center" class="FormInsideTableTopCell">Data Source</td>
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<td height="12" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
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<td height="12" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
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<td height="25" class="FormInsideTableLeftCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
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</table></td>
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<tr>
<td class="FormOuterTableRow"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="15">Procedures:
Biopsies / Cystoscopies</span><span><img src="../../Images/shim.gif" border="0" width="30" height="1">
<input type="checkbox" name="Films Reviewed22">
Reviewed with Pathologist</span><br> <table align="center" border="0" width="650" cellpadding="0" cellspacing="0">
<tr>
<td width="100" align="center" class="FormInsideTableTopLeftCell">Date</td>
<td width="150" align="center" class="FormInsideTableTopCell">Procedure</td>
<td width="400" align="center" class="FormInsideTableTopCell">Results</td>
</tr>
<tr>
<td height="25" class="FormInsideTableLeftCell"> </td>
<td height="12" align="center" class="FormInsideTableRegCell">Cystoscopy</td>
<td height="12" class="FormInsideTableRegCell"><span>
<input type="checkbox" name="office consult2" value="yes">
Not Done</span></td>
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<td height="25" class="FormInsideTableLeftCell"> </td>
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<td height="12" class="FormInsideTableRegCell"> </td>
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<td height="12" class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
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<td height="25" class="FormInsideTableLeftCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
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</table></td> </tr>
<tr >
<td height="14" align="center" valign="bottom" class="blackBoldText">GU12<img src="../../Images/shim.gif" border="0" width="45" height="1">U16<img src="../../Images/shim.gif" border="0" width="45" height="1">CMIC
Approval Date: 6/03<img src="../../Images/shim.gif" border="0" width="45" height="1">rev:09/08/06<img src="../../Images/shim.gif" border="0" width="45" height="1">Page
<span id="PageNumber">3</span> of <span id="TotalPages">6</span><img src="../../Images/shim.gif" border="0" width="45" height="1">B/02.070.<span class="blackBoldTextSmall">12</span></td>
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<img src="../../Images/FormImages/BarCodeLineStatement.gif" border="0" width="8" height="121"></div>
<div class="VerticalBarCodeMRN"><% =BarCodeMRN %></div>
<div class="VerticalBarCodeDocType">*U16*</div>
<div class="VerticalBarCodeAcctType"><% =BarCodeAcctType %></div>
<div class="VerticalBarCodeDate"><% =BarCodeDate %></div>
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