Comprehensive Thoracic Oncology Program Referral Form

DHMC use only

Appt. Date:

___________________

Appt. Time:

___________________

Phone: (603) 650-6344

Comprehensive

Fax: (603) 650-9496

Thoracic Oncology Program

Referral Form

Patient Name: Last __________________________________ First _______________________________ MI ____________

DOB: _______________________________________________ DHMC MR#: _________________________________________

Address: _______________________________________________ City, ST: ________________________ Zip: ___________

Home #: __________________________ Work #: ____________________________ Cell #: ___________________________

Current smoker?

No

Yes

Pack(s) per day __________

# of Years __________

Referring Provider: ______________________________________________________ Office #: _________________________

Contact Person: __________________________________________________________ Fax #: ___________________________

Staff Physician (if different than above): _____________________________________ Office #: _________________________

Information required:

Send to:

In order to coordinate appropriate treatment options and care at the time of your patient’s visit,

the following items must be received:

All office notes, treatment notes, and lab reports

Fax to:

CTOP

Fax: (603) 650-9496

All pertinent Films/Images

Date sent to DHMC: _________________

Send to:

DHMC Film Library

-FedEx/UPS/Courier ONLY

From (hospital):

_________________

One Medical Center Drive

-Do NOT send Regular Mail

Shipping Company: _________________

Lebanon, NH 03756

Tracking No:

_________________

Pathology Slides

Date sent to DHMC: _________________

Send to:

DHMC Pathology

From (hospital):

_________________

Attn: Candice Black, MD

Shipping Company: _________________

One Medical Center Drive

Tracking No:

_________________

Lebanon, NH 03756

Management of Care:

Service requested:

Evaluate and treat at DHMC

Smoking Cessation Program

We/the patient would like a 2

nd

opinion only

Second opinion on films/scans

Please assume a subset of care:

Bronchoscopy/Biopsy – must have films sent

Specify: _________________________________________________

to DHMC first

Prefer consultation with: ____________________________________

Previous Cancer Treatment:

Presenting Symptoms/Diagnosis:

___________________________________________________________

____________________________________________

___________________________________________________________

____________________________________________

___________________________________________________________

____________________________________________

Tests completed: Has patient had PFTs done in the past 90 days?

Yes

No

May we contact the patient to schedule?

Yes

No

If yes, what was the patient told regarding the referral? ____________________________________________________________

Notice regarding confidentiality: This facsimile transmission and the accompanying material contain confidential information from Dartmouth-Hitchcock Medical Center that may be privileged. The

information is for the exclusive use of the addressee named on this transmission sheet. Disclosure, copying, distribution, or use of the contents of the material transmitted by person(s) other than the

intended recipient is prohibited. If you have received this facsimile in error, please notify us immediately by telephone so that we may arrange to retrieve these documents.

Rev. 11-30-10