UNM Cancer Center - Referral/Request Appointment Form

To help us set up an appointment for yourself, your patient, or your loved one, we need a few details. Please fill out the form below. We will call during business hours, 8 am - 5 pm, Monday through Friday.

If you are a patient, please skip to the next section.

Referrals, Are You a:

Your Name:

Your Phone Number:

Who do you want us to call to schedule an appointment?

I am faxing medical records to you.

UNM Cancer Center fax number is 505-272-5458

Patient Information

First Name (required):

Last Name (required):

City:

State:

Phone (required):

Is there a particular doctor you'd like to see?

Cancer Diagnosis

Date of Birth

Insurance