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 & Vascular Center

• Venous Access Device Consultation Request Form (PDF)

Neurology

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

Obstetrics & 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)