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Physician Referral Form
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.
THIS FORM is only for use of healthcare providers and/or affiliates of the hospital. Please scroll down to initial contact or treatment support kit request if you are a patient, client, or loved one.
Want to know more about what we offer and if we have the services to help you? Fill out "CONTACT REQUEST" and one of our board members will be in contact to discuss our services and options.
CONTACT REQUEST
CONTACT REQUEST
Click the Purple Button above to be directed to the initial contact form and one of our coaches will be in contact shortly. (Please allow 48 hours for contact, monitor your "junk" folder in case our response is filtered to your unknown contact folder)
TEXT WAIVER
TEXT WAIVER
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
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