Refer a Patient Form
Provider Information
First name
Last name
Email
Phone number
Fax number
Would you like to add any additional providers?
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No
First name
Last name
Email
Phone number
Fax number
Patient Details
First name
Last name
Phone number
Date of birth
Gender
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Female
Male
Other...
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Does the patient live in the US or Canada?
Yes
No
Insurance
Diagnostic Info
Patient's disease type
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Blood cancer or disorder
Brain and spinal cancer
Breast cancer
Endocrine cancer
Gastrointestinal cancer
Genitourinary cancer
Gynecologic cancer
Head and neck cancer
Lung and thoracic cancer
Renal cancer
Sarcoma
Skin cancer
Other...
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Requested clinic (optional)
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Genetics/High Risk Cancer Prevention Clinics
Survivorship Clinic
Blood and Marrow Transplant Long-Term Follow Up
Cancer and Organ Transplant Clinic
Proton Therapy
Provide additional details, purpose of visit or consult
Fred Hutch should...
Assume complete management of care
Assume 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
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