Forms

Consult Request Form 

Referring Physicians can now complete a Consult Request Form to request an appointment with our specialty clinics. This online form was especially designed to allow you to request appointments at your convenience.

Radiology Requisition

U-M Radiology Services are available at our hospitals and outpatient facilities in various communities. For detail, view Radiology Services by Location.

GI/Hepatology Referral Forms

• Direct Access Capsule
• Direct Access Endoscopy Referral
• Direct Access EUS Referral Form
• FibroScan Request Form
• Hepatology Consult Request Form
• GI Consult Request 
• IBD Clinical Trials Referral Form
• Physiology testing (including breath testing)  (internal only)

Oral & Maxillofacial Surgery Referral Forms

• Wisdom Tooth Clinic Referral
• TMD/Orofacial Pain
• Hospital-Based and Special Care Dentistry 
• OMFS at Michigan Medicine 

Transplantation

• Kidney Transplant Referral Form
• Liver Transplant Referral Form
• Lung Transplant Referral Form

Additional Forms

• Allergy Outpatient Consult Form
• Cardiac CT Form
• CT Questionnaire (internal only)
• ECHO Questionnaire
• Oncology Service Consult Request Form
• Metabolism, Endocrinology & Diabetes (MEND) Outpatient Consult Request
• Methacholine Challenge Patient Preparation Form
• MRI Questionnaire (internal only)
• Nephrology Outpatient Consult Form
• Outpatient Referral Request for Interventional Pulmonology Services
• Pulmonary Division
• Rheumatology Request for Consultation