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  • Specialty Referrals /
  • Make a Referral

Dartmouth Hitchcock Clinics Manchester Referrals

A number of specialty appointment request forms for the Manchester area are available for download. If you have questions, please call the department directly.

See also:

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

Outpatient services

  • Outpatient Referral Form (PDF)

Specialty request forms

Complex Care Primary Clinic

  • Complex Primary Care Appointment/Transition of Care Request Form (PDF)

Endocrinology

  • Endocrinology (Adult) New Patient Referral Appointment Request Form (PDF)

Endoscopy / Colonoscopy

  • Direct Endoscopy or Colonoscopy Referral Form (PDF)

Heart and Vascular Center

  • Venous Access Device Consultation Request Form (PDF)

Neurology

  • Neurology (Adult & Pediatric) and Sleep Medicine Referral Form (PDF)

Obstetrics and Gynecology

  • Prenatal Screening Lab Requisition (PDF) (Women & Infants Hospital)
  • Urogynecology/Reconstructive Pelvic Surgery - Request for Evaluation (PDF)

Pulmonary Medicine

  • Pulmonary Referral Form (PDF)

Radiology

  • CT, MRI and MRA Order/Pre-Authorization (PDF)
  • PET-CT Scan Request (PDF)
  • Prenatal Diagnosis & Maternal Fetal Medicine Referral Form (PDF)

Rheumatology

  • Rheumatology (Adult & Pediatric) Referral Appointment Request Form (PDF)

Surgery

  • General Surgery Referral Form (PDF)

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        • Dartmouth Hitchcock Medical Center Referrals
        • Dartmouth Hitchcock Clinics Manchester Referrals
        • Dartmouth Hitchcock Clinics Nashua Referrals
        • Pediatric Referral Forms (Dartmouth Health Children's)
        • Cancer Referral Forms (Dartmouth Cancer Center)
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