Provider Referral Forms & Instructions

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

Center for Sleep Disorders

• Center for Sleep Disorders – Referral Form

Comprehensive Care & Infectious Diseases Clinic

• Comprehensive Care & Infectious Diseases – Referral Form
• Hepatitis C Referral Form
• Tick-borne Illness Referral Form

Diagnostic Imaging

Referral Forms

• CT Referral/Order Form
• Infusion Services Prescription Order Form
• Nuclear Medicine Worksheet
• Outpatient MRI Order/ Prescreening Questionnaire
• Outpatient Testing Form
• PET/CT Request Form
• Scheduling/Authorization Process for PET/CT
• Verbal Outpatient Order Confirmation Form

Preparation Instructions

• Barium Enema Preparation
• MRI Claustrophobia Guidance
• PET/CT Preparation

Reference Guides

• CT Scans Reference Guide

ENT & Audiology

• ENT & Audiology Referral Form

Foley Cancer Center

• Foley Cancer Center – Outpatient/Inpatient Referral Form

Laboratory

• Laboratory Outpatient Testing Form
• Nursing Home Form
• Surgical Pathology Non-GYN Cytology Form
• Women's Health Test Request Form
• Visiting Nurses Form

Marble Valley Urology

• Marble Valley Urology – Referral Form

Outpatient Rehabilitation

• Outpatient Rehabilitation – Referral Form

Physical Medicine & Rehabilitation

• Physical Medicine & Rehabilitation – Referral Form

Rutland Diabetes & Endocrinology Center

• Rutland Diabetes & Endocrinology Center – Referral Form

Rutland Digestive Services

• Rutland Digestive Services – Referral Form
• Endoscopy Referral Form

Patient Instructions

• Bronchoscopy Instructions
• Colonoscopy Instructions
• Colonoscopy with Miralax^® Instructions
• EGD Instructions
• Flexible Sigmoidoscopy Instructions
• Percutaneous Endoscopic Gastrostomy Placement Instructions
• Upper Procedure (EGD) & Lower Procedure (Colonoscopy) Instructions

Rutland General Surgery

• Endoscopy Referral Form
• Referral Form – General Surgery and Wound Clinic

Rutland Heart Center

• Rutland Heart Center – Referral Form

Rutland Kidney Center

• Rutland Kidney Center – Referral Form

Rutland Pulmonary Center

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

Rutland Regional Behavioral Health

• Rutland Regional Behavioral Health – Referral Form

Rutland Regional Neurology Center

• EMG/NCV Referral Form

Rutland Women's Healthcare

• Rutland Women's Healthcare – Referral Form