Refer a Patient Form

Provider Information

First name

Last name

Phone number

Fax number

Would you like to add any additional providers?

YesNo

First name

Last name

Phone number

Fax number

Patient Details

First name

Last name

Phone number

Date of birth

Gender

Enter other...

Does the patient live in the US or Canada?

YesNo

Patient mailing address

Street Address Line 1

House/building number and street name

Street Address Line 2

Apartment, suite, unit, floor, etc.

City

State/Province/Region

ZIP/Postal Code

Country

Diagnostic Info

Patient's disease type

Enter other...

Requested clinic (optional)

Provide additional details, purpose of visit or consult

Fred Hutch should...

Assume complete management of careAssume a subset of care (with review and input)Provide opinion only

Records for patient will be sent by...

Mail:

Fred Hutchinson Cancer Center
Intake Office, K-135
825 Eastlake Ave E.
Seattle, WA 98109

Fax:

Records should be faxed to: 206.606.1025

Records for patient will be sent by...

Mail:

Fred Hutchinson Cancer Center – Proton Therapy

1570 N. 115th St.
Seattle, WA 98133

Fax:

Records should be faxed to: 206.374.2645

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