Refer a New Patient – Referring Provider Offices Only

This form is for referring provider offices only. If you are a new or existing patient, please click below to request an appointment. https://arizonaoncology.com/appointments

Referring Provider Name

Name of Referring Clinic

Referring Provider Phone #

Phone

Referring Provider Email

Service Requested

Breast Surgery/Breast Surgical Oncology – Cirugía de mama/ Cirugía oncológica de mama

Colorectal / Consulta colorrectal

Gynecologic Oncology / Ginecología oncológica

Hematology / Hematología

Low Dose Radiation for Osteoarthritis / Radiacion en dosis bajas para la osteoartritis

Medical Oncology / Medicina oncológica

Non Oncology / Consulta no oncológica

Radiation Oncology / Radiooncología

Preferred Clinic

Patient First Name

Middle Initial

Patient Last Name

Patient DOB

mm/dd/yyyy

Patient Primary Phone #

Phone

Preferred Provider

(see physician listings: https://arizonaoncology.com/physicians/)

Diagnosis

Reason for Visit

Document Upload

To streamline the referral process, please upload the following documents for the patient you are referring, if applicable.

• Patient Demographics and copy of insurance card

• Last two progress notes

• Discharge summary from most recent hospital admission

• Consult notes from other specialists regarding condition warranting the referral

• If Oncology referral, last 2 lab reports to include any tumor markers (CEA, CA-125, etc.)

• If Hematology referral, must have last 4 lab reports (3-6 months)

• If Breast Cancer, include HER2, Estrogen Receptors (ER), and Progesterone Receptors (PR) reports

• All Pathology reports

• Radiology reports – US, MRIs, CTs, Mammograms, NucMed, PET, etc

• Operative reports and their corresponding pathology reports, if applicable

Drop your files here

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