Hematology

New Patient 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:


Dartmouth Cancer Center

Hours: Monday through Friday, 8 am to 5 pm

Phone 603-650-6272

Fax 603-727-7814


Norris Cotton Cancer Care Pavilion, Lebanon

Dartmouth Hitchcock Medical Center

One Medical Center Drive

Lebanon, NH 03756

Phone: 603-653-3500


Dartmouth Cancer Center Manchester

Notre Dame Pavilion, Catholic Medical Center

87 McGregor Street

Manchester, NH 03102

Phone: 603-629-1828


Dartmouth Cancer Center Nashua

Dartmouth Hitchcock Clinics Nashua

2300 Southwood Drive

Nashua, NH 03063

Phone: 603-577-4170


Dartmouth Cancer Center St. Johnsbury

1080 Hospital Drive

St. Johnsbury, VT 05819

Phone: 802-473-4100

Fax: 802-473-4109



After provider review, some appropriate referrals may be changed to E-consults to expedite response time.


HEMATOLOGY E-CONSULT DISCLAIMER

E-consults are based on the clinical data available to the reviewing provider and are furnished without benefit of a comprehensive evaluation or physical examination. All advice and recommendations must be interpreted in light of any clinical issues, or changes in patient status, not available to the reviewing provider. The ongoing management of clinical problems addressed by an e-consult is the responsibility of the referring provider. If you have further questions or please contact the reviewing provider. If needed, the patient will be scheduled for an in-office consultation.


URGENT REFERRAL DISCLAIMER

Urgent referrals are scheduled following provider review. If your patient has a medical emergency, please direct them to the emergency room for emergent care. After hours/on-call 603-650-5000/request the on-call provider be paged

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Information Required

Please attach office notes, lab reports, pathology reports, and imaging reports.

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