Proton Therapy Referral Form

*Indicates required information

Proton Therapy Referral

Referred By *

Physician Referral

Self 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

Yes

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?

Physician Radio Friend or Family Member
Newspaper or Magazine Mail Online Ad
Internet Search Billboard McLaren Website
Community Event or Seminar Social Media TV-News
Other

If you selected other, please specify:

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Physician	Radio	Friend or Family Member
Newspaper or Magazine	Mail	Online Ad
Internet Search	Billboard	McLaren Website
Community Event or Seminar	Social Media	TV-News
Other