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  • 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.

Specialty request forms

  • Outpatient Referral Form (PDF)
  • Complex Primary Care Appointment/Transition of Care Request Form (PDF)
  • CT, MRI and MRA Order/Pre-Authorization (PDF)
  • Dartmouth Cancer Center at CMC Medication/Infusion Order Form
  • Endocrinology (Adult) New Patient Referral Appointment Request Form (PDF)
  • Endoscopy or Colonoscopy Referral Appointment Request Fom (PDF)
  • General Surgery Referral Request Appointment Form (PDF)
  • Neurology (Adult & Pediatric) and Sleep Medicine Referral Appointment Request Form (PDF)
  • Pediatric referral forms
  • PET-CT Scan Request (PDF)
  • Prenatal Diagnosis & Maternal Fetal Medicine Referral Form (PDF)
  • Prenatal Screening Lab Requisition (PDF)
  • Pulmonary Medicine (Adult) Referral Appointment Request Form (PDF)
  • Rheumatology (Adult & Pediatric) Referral Appointment Request Form (PDF)
  • Urogynecology/Reconstructive Pelvic Surgery - Request for Evaluation (PDF)
  • Venous Access Device Consultation Request Form (PDF)

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