Make a Referral

For Patients:

By choosing Texas Oncology for your cancer treatment needs, you gain the peace of mind that comes from partnering with the nation’s largest network of medical professionals dedicated solely to the treatment of cancer. You will have access to the most advanced therapies and medical equipment for treating cancer available today. And, you will receive the medical guidance, practical advice, and caring support of world-class medical teams dedicated to a single purpose: improving your quality of life and increasing your odds of beating cancer.

If you would like to speak to one of our referral specialists, please complete the following to the best of your knowledge. After you submit this form, one of our referral specialists will call you within 3 business days of receiving your request.

If after viewing this form, you decide that you would prefer to speak with one of our referral specialists, please call between 9:00 am and 5:00 pm, CST, Monday – Friday:
  • Transplant: 214-370-1500
  • Hematology and Oncology: 888-864-4226

*  Type of Referral:

   Transplant
   Hematology and Oncology



* indicates required information

About You

* First Name:
* Last Name:
* Birth Date: / /
* Gender:
   Social Security Number:
At your first appointment, you will be required to present your social security card and driver’s license or other government issued picture identification in order that we may verify that you are a resident of the US.
   Have you been a Texas
   Oncology patient? 		 Yes
  No
Your Contact Information

* Address:
* City:
* State:
* Zip:

* What is your preferred method of contact:     
Please enter the email adress or the phone number at which you would prefer to be reached from 9:00 am - 5:00 pm, CST.

* Primary Phone:

   Alternate Phone:
* Email:
* Confirm Email:
If there is a possibility that you cannot be reached by your primary number please provide an alternative contact person and number.
   Alternate Contact Name:
   Relationship:
   Alternate Phone:
   Alternate Email:
   Confirm Alternate Email:



Insurance Information
   * Carrier:
 
   * Customer Service Phone:  
 
   * Customer Service
      Address: 		 
 
      ID Number:



      Group Number:



      Policy Number:



Please provide the requested insurance information so that we may confirm your benefit program.  We will confirm your insurance coverage prior to your first appointment.
Diagnosis Information

* What type of cancer has
   been diagnosed?



Other Illness: 

Diagnosis Details:
Treatment History


Do you have a primary care provider or oncologist?


If yes, please provide their name and phone number.

After completing and submitting this form, one of our Referral Specialists will call you within three business days after receiving your request.