Comprehensive Breast Program Referral Form

Please submit this form to refer your patient to Dartmouth Cancer Center for a second opinion, consultation, treatment, or follow-up care at the following locations:


Norris Cotton Cancer Care Pavilion, Lebanon

Dartmouth Hitchcock Medical Center

One Medical Center Drive

Lebanon, NH 03756

Phone: 603-653-3500

Fax: 603-643-7311

Email: comprehensive.breast.program@hitchcock.org


Dartmouth Cancer Center Manchester

Notre Dame Pavilion, Catholic Medical Center

87 McGregor Street

Manchester, NH 03102

Phone: 603-629-1828

Fax: 603-695-2855


Dartmouth Cancer Center Manchester

Dartmouth Hitchcock Clinics Manchester

100 Hitchcock Way

Manchester, NH 03104

Phone: 603-695-2840


Dartmouth Cancer Center Nashua

Dartmouth Hitchcock Clinics Nashua

2300 Southwood Drive

Nashua, NH 03063

Phone: 603-577-4170

Fax: 603-640-6882


Dartmouth Cancer Center Keene

Cheshire Medical Center

580 Court Street

Keene, NH 03431

Phone: 603-354-5466

Fax: 603-354-5468


Dartmouth Cancer Center St. Johnsbury

1080 Hospital Drive

St. Johnsbury, VT 05819

Phone: 802-473-4100

Fax: 802-473-4109


Will a supplied interpreter be needed for this appointment?

Comprehensive Breast Program

Please provide details such as location of lump in cm from nipple, which side it's on, the size in cm, any skin changes, if any discharge note color such as: black/brown, red, tan, green, yellow, milky or clear. Also, indicate the type and year of diagnosis or if it is a new diagnosis. If family history, indicate relationship to patient.

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Mammogram/Ultrasound

(Important -- Please specify approximate dates and list all facilities where last three mammograms have been done.)

Management of Care

Service/Appointment Requested (check all that apply):

(Please submit a referral through Familial Cancer Program)

Information Required

All office and treatment notes, mammo and ultrasound reports and current/prior diagnosis can be faxed to: (603) 643-7311

Pathology slides for general surgery or medical oncology referrals can be Mailed/shipped to:

Attn: Pathology Department, DHMC, One Medical Center Dr, Lebanon, NH 03756

Drag and drop files here or