Physician Referral
Scheduling for someone else?

Other Options

Seattle Cancer Care Alliance
825 Eastlake Ave E.
PO Box 19023
Seattle WA 98109-1023

Fax: (206) 288-1025

TTY Washington Relay Service
Call (855) 557-0555

Physician Referral Form

To refer a patient to SCCA, call (206) 288-SCCA (7222) or complete the form below. SCCA also offers U-Link, a secure system that allows referring physicians access to information about their patients. (* denotes required field). Download this PDF to view the complete list of SCCA/UW oncology providers by specialty.

Referring Physician
Please check here if you are an SCCA Network Physician

Patient Details
* 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.
* Purpose of visit or consult
Please screen this patient for the following Phase 1 Program trial at SCCA:

MDX-1105 for Advanced or Recurrent Cancer (UW08038)(UW08038)
A Phase 1, Open-label, Dose-escalation, Multidose Study of MDX-1105 Administered Every 14 Days in Subjects With Selected Advanced or Recurrent Solid Tumors
Referral to Specialty Service
Breast Cancer
Gastrointestinal Cancer
Gynecologic Cancer
Head, Neck and Lung Cancer
Marrow/Stem Cell Transplant
Prostate Cancer
Proton Therapy
Renal and Melanoma
* Patient Records
We will send records.
Records should be sent to: Seattle Cancer Care Alliance, Intake Office, E2-102, 825 Eastlake Ave E, Seattle, WA 98109.
We will fax records.
Records should be faxed to:
Files should include medical records pertaining to the patient's original diagnosis through present and any treatment thus far. This includes chart notes, pathology reports, and radiology reports, laboratory reports for the last six months, surgical reports and treatment reports/summaries (ie: chemo flow sheets, radiation treatment reports).
Other Treating Physicians (optional)
Additional Comments

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