Adult Referral Forms (DHMC)

Referring physicians needing referral forms may call the Physician 连接ion Center to request the appropriate document. If you have any questions or having access problems, please 十大正规博彩网站评级正规博彩平台.

Please note: We do not take referrals by phone.

Referral forms are available below in PDF format.

参见:

• Pediatric referral forms (Dartmouth 健康 Children's)
• Cancer referral forms (Dartmouth Cancer Center)

Outpatient services

• Outpatient Referral Form (PDF)
• 历史 and Physical Exam Form - Pre-procedure (PDF)

Specialty request forms

Center for Pain and Spine

• Center for Pain and Spine Referral Form (PDF)

Dermatology

• Dermatology Referral Form (PDF)

Diagnostic Coagulation Center

• Coagulation Diagnostic Referral Form (PDF)

Endocrinology

• Endocrinology, Diabetes, and Metabolism Referral Form (PDF)
• Diabetes Self Management Program Referral Form (PDF)

Gastroenterology and Hepatology

• Fibroscan® Referral Form (PDF)
• Endoscopy Order Procedure Form (PDF)
• Motility Referral Lab Form (PDF)
• New Outpatient Consult Order (non-procedure) (PDF)

Heart and Vascular Center

• Cardiology Non-Invasive Appointment Request Form (PDF)
• Vascular Access Service (VAS) Request for PICC Placement Referral Form (PDF)
• Vascular 手术 Laboratory Order Form (PDF)

Hypertension and Nephrology

• Hypertension and Nephrology Referral Form (PDF)

Infectious Disease and International 健康

• Post-Acute COVID Syndrome (PACS) Clinic Referral Form (PDF)

神经学

• DHMC Electroencephalography (EEG) and Evoked Potential Request Form (PDF)

Obstetrics and Gynecology

• Abnormal Pap and/or Colposcopy Evaluation Form (PDF)
• Female Pelvic Medicine and Reconstructive 手术 (Urogynecology) Referral Form

Pulmonary Medicine

• Function Lab Referral Form (PDF)
• Outpatient Pulmonary Rehabilitation Program Referral Form (PDF)

放射学

• Breast Imaging Request Form (PDF)
• CT Chest Lung Cancer Screening Imaging Request (PDF)
• CT安全 & Scheduling Questonnaire (PDF)
• DXA Bone Density Questionnaire (PDF)
• DXA Order Form (PDF)
• Imaging Request Form (PDF)
• Maternal-Fetal Medicine & Prenatal Diagnosis Program Referral Form (PDF)
• MRI Safety & Scheduling Questionnaire (PDF)
• Nuclear Medicine Stress Test Referral Form (PDF)
• PET Scan Request Form (PDF)
• Screening Lab Requisition Form (PDF)
• Ultrasound Obstetrical Referral Form (PDF)
• Ultrasound Pelvic Referral Form (PDF)

Rehabilitation Medicine

• Rehabilitation Medicine Outpatient Referral Form (PDF)

Rheumatology

• Rheumatology Referral Form (PDF)

Sleep Medicine

• Sleep Disorders Center Referral Form (PDF)
• Cheshire Medical Center:
  • Part 1 (PDF)
  • Part 2 (PDF)
• Littleton Regional Hospital (PDF)

手术

• General 手术 Referral Form (PDF)
• Oral and Maxillofacial 手术 Referral Form (PDF)