For Referring Providers

Center for Sleep Disorders

• Center for Sleep Disorders – Referral Form (pdf)

Diagnostic Imaging

Referral Forms

• CT Referral/Order Form (pdf)
• Nuclear Medicine Worksheet (pdf)
• Outpatient MRI Order/ Prescreening Questionnaire (pdf)
• Diagnostic Imaging Outpatient Test Ordering Form (pdf)
  
  • MR Referral Order Testing Form (pdf)
  • Outpatient Contrast Injection Ordering Form (pdf)
  • Ultrasound Ordering Form (pdf)
  • Mammography, Ultrasound Breast and Bone Density Ordering Form (pdf)
• Lung Cancer Screening Order Form (pdf)
• PET/CT Request Form (pdf)
• Pylarify PET/CT Order Form (pdf)
• Scheduling/Authorization Process for PET/CT (pdf)
• Verbal Outpatient Order Confirmation Form (pdf)

Preparation Instructions

• Barium Enema Preparation (pdf)
• MRI Claustrophobia Guidance (pdf)
• PET/CT Preparation (pdf)

Reference Guides

• CT Scans Reference Guide (pdf)

ENT & Audiology

• ENT & Audiology Referral Form (pdf)

Foley Cancer Center

• Foley Cancer Center – Outpatient/Inpatient Referral Form (pdf)

Infusion Services

• Infusion Services Prescription Order Form (pdf)
• Outpatient Antimicrobial Therapy Prescription Order Form (pdf)
• Denosumab (Prolia) Prescription Order Form (pdf)
• Eculizumab (Soliris) Prescription Order Form (pdf)
• Natalizumab (Tysabri) Prescription Order Form (pdf)
• Ravulizumab (Ultomiris) Prescription Order Form (pdf)
• Testosterone Undecanoate (Aveed) Prescription Order Form (pdf)

Laboratory

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

Marble Valley Urology

• Marble Valley Urology – Referral Form (pdf)

Outpatient Rehabilitation

• Outpatient Rehabilitation – Referral Form (pdf)

Physical Medicine & Rehabilitation

• Physical Medicine & Rehabilitation – Referral Form (pdf)

Rutland Diabetes & Endocrinology Center

• Rutland Diabetes & Endocrinology Center – Referral Form (pdf)

Rutland Digestive Services

• Rutland Digestive Services – Referral Form (pdf)
• Endoscopy Referral Form (pdf)

Patient Instructions

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

Rutland General Surgery

• Endoscopy Referral Form (pdf)
• Referral Form – General Surgery and Wound Clinic (pdf)

Rutland Heart Center

• Rutland Heart Center – Referral Form (pdf)

Rutland Kidney Center

• Rutland Kidney Center – Referral Form (pdf)

Rutland Pulmonary Center

• Pulmonary Rehabilitation Referral Form (pdf)
• Rutland Pulmonary Center Referral Form (pdf)

Rutland Regional Behavioral Health

• Rutland Regional Behavioral Health – Referral Form (pdf)

Rutland Regional Neurology Center

• Neurology New Patient Referral Form (pdf)
• EMG/NCV Referral Form (pdf)

Rutland Women's Healthcare

• Rutland Women's Healthcare – Referral Form (pdf)