Initial Client Applications
Physician Referral Form
This form only is to be used by medical offices, physicians, nurses, or their ancillary members of the medical field to refer a patient for support services.
Our board members recognize your time is valuable, and we appreciate your understanding of our volunteer's time as well. A majority of our board members and volunteers work full time jobs while remaining fully committed to MFITF organization.
There are certain situations in which text message is the quickest and fastest way to communicate certain questions and non-emergent matters. If you are open to text messaging with your cancer coach/MFITF board member (on occasion) please fill out this waiver so you are aware of the privacy differences in text versus communication through our HIPPA compliant system or telephone.
Click the Purple link above to complete the text messaging waiver