Proton Therapy Referral Form

*Indicates required information

Proton Therapy Referral

Referred By *

Physician ReferralSelf Referral

Patient Phone Number: *

Best time to call: *

Primary Physician:

Primary Physician Office Phone:

Referral Information

Diagnosis/reason for referral: *

Previous diagnosis of cancer:

Previous radiation treatment

YesNo

Specialist Phone:

McLaren Physician Requested:

Patient Insurance Information

Insurance Group Number: *

Contract Number:

Referring Physician Information

Referring Physician Name: *

Referring Physician Address: *

Referring Physician City, State, Zip Code: *

Referring Physician Phone Number: *

Referring Physician Office Fax *

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 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.

Self-Referral: How did you hear about the McLaren Proton Therapy Center?

PhysicianRadioFriend or Family Member
Newspaper or MagazineMailOnline Ad
Internet SearchBillboardMcLaren Website
Community Event or SeminarSocial MediaTV-News
Other

If you selected other, please specify:

Page Loading