Provider Referral Forms and Instructions

Providers can access and download referral forms for patient procedures and appointments. Providers and patients can also download preparation instructions for certain procedures.

Comprehensive Care & Infectious Diseases Clinic

• Referral Form

Diagnostic Imaging

Referral Forms

• CT Referral/Order Form
• IVP/Venogram Referral Form
• Outpatient MRI Order/ Prescreening Questionnaire
• PET/CT Request Form
• Scheduling/Authorization Process for PET/CT
• Telephone Outpatient Clinic Order

Preparation Instructions

• Barium Enema Preparation
• CAT(Computerized Axial Tomography) Scan Preparation
• Intravenous Pyelogram (IVP) Preparation

After Care

• Instruction for Patients on Metformin

Rutland Diabetes & Endocrinology Center

• Referral Form

Rutland Digestive Services

• Referral Form

ENT & Audiology

• Referral Form

Foley Cancer Center

• Outpatient/Inpatient Referral Form

Rutland Heart Center

• Referral Form

Rutland Kidney Center

• Referral Form

Outpatient Rehabilitation 

• Referral Form

Physical Medicine & Rehabilitation

• Referral Form

Rutland Pulmonary Center

• Asthma Education Referral Form
• COPD Transition Referral Form
• In-Home Asthma Program Referral Form
• Pulmonary Rehabilitation Referral Form
• Rutland Pulmonary Center Referral Form

Center for Sleep Disorders

• Referral Form

Rutland Women's Healthcare

• Referral Form