Request an appointment / Refer a patient

This form is for patients to use in requesting an appointment and for physicians to use to refer a patient.

If you would prefer to speak with a patient services representative at VCU Massey Cancer Center or one of our referral coordinators about an appointment, please call (804) 828-5116, or toll-free (877) 4-MASSEY [(877) 462-7739], Monday through Friday, from 8 a.m. until 4:30 p.m.

To help us help you, please fill in all relevant fields. When you are finished, please click the “Submit” button at the bottom of the form to send your request. We will contact you within one business day of receipt.

* Required Field

Note: Please include area code with all phone numbers.

Information about person sending this form

Full name of sender*
Sender’s daytime phone number* ()
Sender’s e-mail address

Information about the patient

Full legal name*
Home address*
City*
State*
ZIP code*
Country
Daytime phone number* ()
Evening phone number ()
Mobile (cell) number ()
Emergency contact name
Emergency contact number ()
E-mail address
Date of birth*
Gender: Male Female
Reason for referral (type of cancer or problem)*
Health insurance company

Information about the referring physician (if applicable)

Referring physician name
Physician’s practice name and address
Physician’s phone number ()
Physician’s e-mail address

Information about patient’s primary care physician

Name of primary care physician*
Physician’s practice name and address
Primary care physician’s phone number* ()
Physician’s e-mail address
Patient will be contacted in order to review insurance coverage or to obtain additional demographic and medical information. If you would like to leave a message for Massey’s patient appointment coordinator, please type it here.