Radiation Oncology Referral Form

Radiation Oncology

Referral Form

Norris Cotton Cancer Care Pavilion, Lebanon

Dartmouth Hitchcock Medical Center

One Medical Center Drive

Lebanon, NH 03756

Phone: 603-650-6600

Dartmouth Cancer Center St. Johnsbury

1080 Hospital Drive

St. Johnsbury, VT 05819

Phone: 802-473-4109

Dartmouth Cancer Center

Hours: Monday through Friday, 8 am to 5 pm

Call toll free: 866-DHMC-DOC or 866-346-2362

Locally, dial: 603-653-1999

Referring Provider*

Office Phone*

Practice Name

Fax*

Practice Address

PCP Name

Patient Name*

MRN #

DOB*

Cell Phone*

Home Phone

Work Phone

Mailing Address*

Interpreter needed for appointment?

Select

Language

Health Insurance

Subscribers Name

Policy #

Group #

Subscriber's DOB

Presenting Symptom/Diagnosis*

Select

Clinical Comments*

Required Attachments

Attach the following:

Operative notes, physician notes, pathology report, radiology reports (CT, MRI, PET), chemotherapy notes and radiation notes (including dose information)

File Upload

Drag and drop files here or

Required Materials

All pertinent films need to be sent for review to:

Dartmouth Hitchcock Medical Center

Department of Radiation Oncology

1 Medical Center Drive

Lebanon, NH 03756

Pathology Slides/Blocks **all outside pathology slides need to be sent to DHMC for review.

Pathology Department, DHMC

1 Medical Center Drive

Lebanon, NH 03756

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