Proton Therapy General Form

Schedule a Call with a Patient Care Coordinator

Thank you for your interest in proton therapy. Please take a moment to fill out the form to have a patient care coordinator call you.

Once the form is completed, you will receive a confirmation email. Our team generally returns calls within 48 hours Monday through Friday between 8:00 a.m. and 4:00 p.m. If you would like to speak with a patient care coordinator quickly, please call us at 206.306.2800.

First name

Last name

Phone number

Secondary phone number

Preferred call back time

About you

What disease are you seeking treatment for?

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Has your medical oncologist recommended radiation therapy?

The following applies to my diagnosis:

Other diagnosis (example: multiple comorbidities)

Additional comments

How did you hear about us?

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Checklist of Items You Will Need for Your Initial Call with Us

You provide:

Demographic information (legal name, etc.)
Insurance information
Related doctor and facility information

You provide:

Demographic information (legal name, etc.)
Insurance information
Related physician and facility information

You provide:

Demographic information (legal name, etc.)
Insurance information
Related doctor and facility information
Name of ophthalmologist