Columbia Basin Hematology & Oncology
Questions? (509) 783-0144

 New Patient Scheduling Information

To help us schedule a hematology or oncology consultation, please submit this form and fax the requested medical records

To:
Fax #:
 
Patient Name:
DOB:
Address:
City:
State:
Zip:
Phone:
Insurance

Our physicians are interested in the following information:

Reason for referral:

The patient's symptoms:

How long the symptoms have been present:

Does the patient know the reason for the referral?

Please fax the following reports and records for a consultation:

  • Chart notes (both oncology and hematology)
  • Pathology reports (oncology)
  • CT and/or MRI reports (oncology)
  • Lab reports/blood counts (both oncology and hematology)
  • Coagulation test results (hematology)
Referring Physician:
Phone:
Fax:

 

 

7360 W. Deschutes Ave.
Kennewick, WA 99336
(509)783-4637

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