Patient Intake Form – PSMA (Pluvicto)

Thank you for your interest in our PSMA (Pluvicto) treatment for advanced prostate cancer. We want to help you find out if Pluvicto 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 (Pluvicto) 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 Information

Name(Required)

First Last

Email(Required)

Phone(Required)

Medical Information

Have you been treated with androgen receptor (AR) pathway inhibition?(Required)

Yes

Have you been treated with taxane-based chemotherapy?(Required)

Yes

Please add any additional comments that are relevant to your case.

Date of birth(Required)

Address(Required)

Street Address City State ZIP Code

Insurance information

Note to patients: Self-pay for the full PSMA (Pluvicto) treatment may exceed $400,000.

Will you be seeking insurance coverage for Pluvicto or will you be self-pay?(Required)

Insurance

Self-pay

Note to patients: Self-pay for the full Lu177 Pluvicto treatment exceeds $400,000 for six treatments.

Insurance provider(Required)

Insurance group number(Required)

Member ID(Required)

Physician Information

Please 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

Referring physician name

First and last name

Referring physician specialty

(ex. oncologist; urologist)

Referring physician practice name

Referring physician address

Street Address City State ZIP Code

Referring physician phone

Referring physician fax

Please add any additional comments that are relevant to your case.