Referral Forms - Adult

Referring physicians in need of referral forms may call the Physician Connection Center to request the appropriate document. If you have questions or are having access problems, please call us toll-free at the Physician Connection Center.

Referral forms are available below in PDF format.

Pediatric Referral Forms are available here.

Downloadable referral forms - Adult

• Dartmouth Hitchcock Medical Center Outpatient Referral Form (PDF)
• Abnormal Pap/Colposcopy Evaluation Form (PDF)
• Cardiology Non-Invasive Appointment Request Form (PDF)
• Center for Pain and Spine Referral Form (PDF)
• Coagulation Diagnostic Referral Form (PDF)
• Comprehensive Breast Program Referral Form (PDF)
• Dermatology Outpatient Consult Referral Form (PDF)
• Diabetes Self Management Program Referral Form (PDF)
• Electroencephalography (EEG) and Evoked Potential Request Form (PDF)
• Endocrinology Referral Guidelines (PDF)
• Familial Cancer Program Referral Form (PDF)
• Fibroscan® Referral Form (PDF)
• Gastroenterology:
  • Endoscopy Procedure Form (PDF)
  • Motility Referral Lab Form (PDF)
  • Outpatient Referral Form (PDF)
• History & Physical Exam Form - Pre-procedure (PDF)
• Oral and Maxillofacial Surgery Referral Form (PDF)
• Pain Management Referral Form (PDF)
• Post-Acute COVID Syndrome (PACS) Clinic Referral Form (PDF)
• Prenatal:
  • Diagnosis & Maternal Fetal Medicine Referral Form (PDF)
  • Screening Lab Requisition Form (PDF)
• Pulmonary:
  • Function Lab Referral Form (PDF)
  • Rehabilitation Referral Form (PDF)
• Radiology:
  • Breast Imaging Request Form (PDF)
  • CT Chest Lung Cancer Screening Form (PDF)
  • CT Safety & Scheduling Questonnaire (PDF)
  • DXA Bone Density Questionnaire (PDF)
  • DXA Order Form (PDF)
  • Imaging Request Form (PDF)
  • MRI Safety & Scheduling Questionnaire (PDF)
  • Nuclear Medicine Stress Test Referral Form (PDF)
  • PET Scan Request Form (PDF)
  • Ultrasound Obstetrical Referral Form (PDF)
  • Ultrasound Pelvic Referral Form (PDF)
• Rehabilitation Medicine Outpatient Referral Form (PDF)
• Rheumatology Referral Form (PDF)
• Sleep Disorders Center:
  • Referral Form (PDF)
  • Cheshire Medical Center Referral Form (PDF)
• Spine Referral Form (PDF)
• Thoracic Oncology and Pulmonary Endoscopy Request Form (PDF)
• Vascular:
  • Access Service (VAS) Request for PICC Placement Referral Form (PDF)
  • Laboratory Order Form (PDF)
• Urogynecology Request for Evaluation Form (PDF)