Physician Referral Form : University of Minnesota Physicians

Request for Consultation or Referral

For use by physicians and their staff

Referring Physician Information

Patient Information

Requested Appointment

For consultation or referral (symptoms or diagnosis)

Insurance Information


We value our relationship with you, your patients, and your office staff. We work hard to keep you informed of your patients' care by providing detailed reports, from diagnosis to treatment and follow-up. Our goal is to provide you with prompt service and communication for the patients that you refer to us.