Karmanos Cancer Institute at McLaren Flint Referral Form

We value the confidence you place in the Barbara Ann Karmanos Cancer Institute at McLaren Flint when you refer your patients to us for cancer care. To make it as easy as possible for you to refer your patients to our cancer center, please fill out the form below and a Karmanos representative will respond to your request as soon as possible.

*Indicates required information

Refer a Patient

Patient Information

Referral Information

Patient Insurance Information

Referring Physician Information

Additional Information Needed

Pathology report (path slides will need to be requested**)

Most recent scans – CT, PET, MRI, Bone Scan, etc. on CD in DICOM format along with reports**

All labs

Chart Notes

Previous cancer treatment including chemotherapy flow and/or radiation flow sheets

Surgeon/Medical Oncologist/Radiation Oncologist name and contact information, if applicable

**If Karmanos Cancer Institute at McLaren Flint and/or the McLaren Proton Therapy Center receives a signed Authorization to Release Medical Records form from the patient, we can request these items on the patient’s behalf.