Brain Tumor Program

Physician Referral

Complete this form to begin the patient referral process. A representative in your office will be contacted by one of our Referral Specialists to collect additional information. The patient will be contacted and the appointment confirmed.

Disclosure of your social security number (SSN) is requested from you in order for The University of Florida Pediatric Brain Tumor Program to process your referral. No statute or other authority requires that you disclose your SSN for this purpose and we may not deny services if you choose not to disclosure it. Failure to provide your SSN, however, may result in the creation of a duplicate patient number being issued, which may lead to multiple medical records. Further disclosure of your SSN is governed by the Florida Public Information Act and other applicable law.

Information about the Referring Physician

First Name
Last Name
Street Address
City
State
Zip
Country
Office Phone
Office Fax
* Physician's Email

Information about the Patient

* First Name
* Last Name
Street Address
City
State
Zip
Country
SSN (xxx-xx-xxxx) (Why do we ask this?)
* Date of Birth (mm/dd/yyyy)
* Gender Male Female
* Daytime phone
* Evening Phone
Fax

Diagnosis Information

* Select Primary
Cancer Diagnosis
* Diagnosis Date (mm/dd/yyyy)
Diagnosis Method
Specify if other or type of screening

Treatment Information

Is the patient currently
under treatment?		 Yes No
Treatment method
Specify if other

Referral Information

Are you referring to
a specific physician?		 Yes No
Physician Name

One of our Referral Specialists will call your office to discuss this referral further and to obtain additional information pertinent to this patient. Please indicate the contact person who can best assist with this referral.

First Name
Last Name
Contact Title
Daytime Phone/Ext.

Your patient will also be contacted in order to review insurance coverage and obtain additional demographic information. Medical and financial eligibility will need to be established prior to confirming an appointment. If you would like to leave a message for the New Patient Referral Office, please type it here.

All E-Mail Referral Forms will receive a response within 24 hours excluding weekends and holidays. The New Patient Referral Office is open Monday through Friday from 8:00 a.m. to 4:00 p.m. EST (1-352-392-5633).

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