Patient Referrals

Patient Referral Form

To refer a patient to Mojave Cancer Center, please call us at (760) 242-9999. You can also fill out and submit our Patient Referral Form below.

Once we receive your form submission, we will call your patient and schedule an appointment. We will keep you informed of your patient’s reason for treatment and progress. Thank you in advance for your patient referral!





Patient Information






Emergency Contact




Physician Information







Insurance Information






Other Information
















We appreciate it if you can fax us the following information prior to your referred patient's appointment:

  • Consultation notes
  • Lab and pathology reports
  • XRAY and scan reports
  • Radiology reports and images (bring either the CD or film)
  • Any prior radiation records (if applicable)
  • Treatment records: Chemotherapy; Radiation
  • Operative reports
  • Hospital discharge summaries
  • Copy of your patient's insurance card, front and back