University of Minnesota Physicians
Request for Consultation or Referral - Adult

For use by physicians and their staff

  Referring Physician Information
Consult or Referral? Consult Referral
Referring Physician's Name
Clinic Name *
Clinic Address
City   State   Zip
Telephone Number   Fax Number
Contact Name *
Contact's Direct #
  Patient Information
Patient's Name *
City   State   Zip
Date of Birth
Parent's Name (if minor)
Spouse's Name (if any)
Previous Name (if any)
Mobile Telephone Number
Home Telephone Number
Work Telephone Number
Contact Instructions
(preferred number,
best time to reach,
OK to leave message, etc.)
  Requested Appointment
Reason for Consultation or Referral
(symptoms and diagnosis)
Pertinent Prior Surgery or Testing
(specify dates)
Specialty Requested *
Physician Requested (if any)
  Insurance Information
Policy Holder
Group #
ID #
Insurance Company

* = required field

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.