NIR Referral Form

Physician Requested*

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

FirstLast
Patient DOB:*

MonthDayYear
Best phone number to contact patient:*
Please enter a valid phone number.
Reason for Referral
Summary of Clinical History:*
Medical History
Patient's History:*

Medical History located in Allina ChartI will Fax to (612) 863-1444Other (Please Specify Below)
If your patient has a history of renal insufficiency, please indicate the following:

CreatinineGFR
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:*

PrefixFirstLast
Clinic/Facility Name:
Contact Person:*

FirstLast
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
Neurointerventional Radiology
Sandee Verootis, Neurointerventional Coordinator
Email: sandee.verootis@allina.com
Phone: (612) 863-4808
Should be Empty:

Patient Information