Forms

Consult Request Form 

Referring Physicians can now complete the Outpatient 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

For direct assistance to schedule appointments for patients who need urgent outpatient consultation with a specialty gastroenterologist.

Suzanne Taylor, RN
Phone: 734-232-9424
Fax: 734-936-5458
E-mail: [email protected]

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

Oral & Maxillofacial Surgery Referral Forms

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

Transplantation

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

Additional Forms

• Allergy Outpatient Consult Form
• Cardiac CT Request Form
• CT Questionnaire (Outpatient)
• ECHO Questionnaire
• Metabolism, Endocrinology & Diabetes (MEND) Outpatient Consult Request
• Methacholine Challenge Patient Preparation Form
• Nephrology Outpatient Consult Form
• Neurosurgery Consult Request Form
• Oncology Service Consult Request Form
• Outpatient Endocrine Dynamic Testing Request
• Outpatient Referral Request for Interventional Pulmonology Services
• Pediatric Pulmonology External Referral
• Pulmonary Division
• Rheumatology Request for Consultation