Dartmouth-Hitchcock Manchester Referrals

A number of Specialty Appointment Request forms for the Manchester area are available for download and more will be added over time. If you have questions, please call the department directly.

Specialty request forms

• Dartmouth-Hitchcock Outpatient Referral Form (PDF)
• CHaD pediatric referral forms
• CT, MRI and MRA Order/Pre-Authorization (PDF)
• Endocrinology (Adult) New Patient Referral Appointment Request Form (PDF)
• Endoscopy or Colonoscopy Referral Appointment Request Form (PDF)
• General Surgery Referral Request Appointment Form (PDF)
• NCCC at CMC Medication/Infusion Order Form
• Neurology (Adult & Pediatric) and Sleep Medicine Referral Appointment Request Form (PDF)
• 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)