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Benefis Sletten Cancer Institute Referral Form

Date: Referring Physician Information Physician:  *Fax #:  *Phone #:  *Patient Information Patient Name:  *Patient Date of Birth:  *Patient Address: Patient Sex: Patient Primary Phone:  *Patient Secondary Phone: Diagnosis:  *

If this is an urgent referral, please contact Patient Navigation at (406) 731-8200.

 Sletten Cancer Institute Physicians: Medical Oncology - Hematology:  *

Radiation Oncology:  *

Gynecologic Oncology:  *Genetic Counseling:  *

In order for our physician to provide you and your patient with the best possible consultation, we will need the following medical records PRIOR to the scheduled appointment:


  • Referring physician notes, initial consult

  • Operation notes, procedure notes

  • Hospital records

  • Current medications

  • Most recent lab work (last 3 visits)

  • Pathology Reports

  • Radiology Images and notes

  • Insurance

 Attach Files: Attach Files: Attach Files: Attach Files: Attach Files: Additional Questions or Comments: 

Records can also be faxed to 1-(406) 731-8100.
A Navigator will coordinate patient care accordingly and notify referring provider plan of care.

 
 

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