Patient Referral Form

Please fill in all fields below to submit a Patient Referral request. All fields are required except those marked Optional.

Send physical patient records to:

Seattle Cancer Care Alliance
Attn. Intake Dept  E2-102
825 Eastlake Ave. E.
Seattle, WA  98109

or FAX to: (206) 288-1025

Referring Physician

Your Full Name
Phone Number
Fax Number
E-Mail Address

Management of Care

	Please assume complete management of patient.
	Please assume a subset of care. We have developed a plan for the patient and would like you to review for input.
	We would like your opinion only.

Appointment Scheduling

	Please notify me of patient's appointment and I will inform the patient.
	Please contact patient directly about their appointment. The patient's phone number is:

Patient Details

Full Name
Date of Birth
Diagnosis

Purpose of visit or consult:

Referral to Specialty Service

	Breast Cancer
	Gynecologic Cancer
	Lung Cancer
	Marrow/Stem Cell Transplant
	Prostate Cancer
	Sarcoma Service
	Other:

Patient Files There are some cases where the patients are asked to carry their films and/or slides to SCCA on appointment day, and other cases where these items should be sent in advance. Please indicate your instructions:
	Patient will carry files and/or slides.
	We will send patient files and/or slides. Films and slides should be sent to: Seattle Cancer Care Alliance, Intake Office, M/S G-4810, 825 Eastlake Ave E, Seattle, WA 98109.

Referring Physicians (optional) Please list the physicians involved in this patient's care (this information will be used to identify which physicians will have access to the patient's records, both online via U-link and via normal postal routes). Use the Notes/Comments field if you need to enter more Referring Physicians.
1)	Physician's Name
	Specialty
	Phone Number
	Fax Number
2)	Physician's Name
	Specialty
	Phone Number
	Fax Number
3)	Physician's Name
	Specialty
	Phone Number
	Fax Number

Notes/Comments (optional)