VIR Referral Form

Physician Requested*

Any AvailableOther (Please Specify Below)
Patient Information
Patient Name:*

First NameLast Name
Patient DOB:*

MonthDayYear
Date
Best phone number to contact patient:*
Please enter a valid phone number.
Reason for Referral
Type of Service Requested:*

ConsultationTreatmentImagingSecond OpinionOther (Please Specify Below)
Summary of Clinical History:
History & Physical Exam
Patient's History:*

Medical History located in Allina ChartI will Fax to (612) 863-1444Other (Please Specify Below)
List Patient's Allergies (i.e. contrast, etc.):*
Imaging Information
Please indicate below how we will be receiving the imaging information on the patient:*

Imaging completed through AllinaImaging completed only through Consulting Radiologists, Ltd (CRL)Other (Please Specify Below)
Imaging Completed (Modality, Location, Date):
Referring Provider Information
Referring Physician:*

PrefixFirst NameLast Name
Clinic/Facility Name:
Physician Phone Number:*
Please enter a valid phone number.
Contact Person:*

First NameLast Name
Contact Phone Number*
Please enter a valid phone number.
Scheduling Instructions
Please indicate who we should contact to schedule:*

Contact the Referring PhysicianContact Office to ScheduleContact Patient to ScheduleOther
Vascular & Interventional Radiology
Sarah Langaard, Interventional Coordinator
Email: sarah.langaard@allina.com
Phone: (612) 863-9668
Should be Empty:

Patient Information