Forms and Brochures

Nevada Radiation Exposure Screening and Education Program (RESEP)


Brochures and Information

Patient Forms: New

  • Information Sheet [pdf]
    Last Updated: December 10, 2013

    The information sheet includes all the information you will need for your appointment.

  • New Patient Questionnaire [pdf]
    Last Updated: August 30, 2013

    Required: The History and Physical Questionnaire form is required for all new patients.

  • Registration Form [pdf]
    Last Updated: August 28, 2013

    Required: The registration form is required.

  • Release Medical Information Form [pdf]
    Last Updated: June 11, 2003

    Optional: Fill out this form only if you would like your results sent to your doctor in addition to you

  • Survey [pdf]

    Required: Information provided in this survey helps Nevada RESEP improve its outreach efforts and can be helpful in obtaining continued funding for the program.

Patient Forms: Returning

  • Information Sheet [pdf]
    Last Updated: December 10, 2013

    The information sheet includes all the information you will need for your appointment.

  • Returning Patient Questionnaire [pdf]
    Last Updated: September 25, 2013

    Required: The History and Physical Questionnaire form is required for all returning patients.

  • Registration Form [pdf]
    Last Updated: August 28, 2013

    Required: The registration form is required.

  • Release Medical Information Form [pdf]
    Last Updated: June 11, 2003

    Optional: Fill out this form only if you would like your results sent to your doctor in addition to you

  • Survey [pdf]

    Required: Information provided in this survey helps Nevada RESEP improve its outreach efforts and can be helpful in obtaining continued funding for the program.

RECA Applications

Utilities

The following applications and applets may be used to open the files on this page.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under Grant H1GRH27374, Radiation Exposure Screening and Education Program, in the amount of $608,972, Grant Period Sept. 2014-Aug. 2017. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.