Proton Therapy Referral Form

*Indicates required information

Proton Therapy Referral

Patient Information

Referral Information

Patient Insurance Information

Referring Physician Information

Additional Information Needed

Pathology report (path slides will need to be requested**)

Most recent scans – CT, PET, MRI, Bone Scan, etc. on CD in DICOM format along with reports**

All labs

Chart Notes

Previous cancer treatment including chemotherapy flow and/or radiation flow sheets

Surgeon/Medical Oncologist/Radiation Oncologist name and contact information if applicable

**If the McLaren Proton Therapy Center receives a signed Authorization to Release Medical Records form from the patient, we can request these items on the patient’s behalf.