Referring physicians needing 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.
See also:
- Pediatric referral forms (Dartmouth Health Children's)
- Cancer referral forms (Dartmouth Cancer Center)
Outpatient services
Specialty request forms
Center for Pain and Spine
Dermatology
Diagnostic Coagulation Center
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 Surgery Laboratory Order Form (PDF)
Hypertension and Nephrology
Infectious Disease and International Health
Neurology
Obstetrics and Gynecology
- Abnormal Pap and/or Colposcopy Evaluation Form (PDF)
- Female Pelvic Medicine and Reconstructive Surgery (Urogynecology) Referral Form
Pulmonary Medicine
Radiology
- Breast Imaging Request Form (PDF)
- CT Chest Lung Cancer Screening Imaging Request (PDF)
- CT Safety & 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
Rheumatology
Sleep Medicine
- Sleep Disorders Center Referral Form (PDF)
- Cheshire Medical Center:
- Littleton Regional Hospital (PDF)