NIR Referral Form

Physician Requested

Other (Please Specify Below)
Patient Information
Patient Name:

FirstLast
Patient DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Best phone number to contact patient:
Please enter a valid phone number.Format: (000) 000-0000.
Reason for Referral
Summary of Clinical History:
Medical History
Patient's History:

Other (Please Specify Below)
If your patient has a history of renal insufficiency, please indicate the following:
List Patient's Allergies (i.e. contrast, etc.):
Imaging Information
Please indicate below how we will be receiving the imaging information on the patient:

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.Format: (000) 000-0000.
Scheduling Instructions
Please indicate who we should contact to schedule

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

Patient Information