University of Michigan Hospitals & Health Centers
Patient Consult Request

Date:

Patient Information:

Patient CPI #:

First Name: : Last Name: A

Age:

Outpatient -----Phone # Alternate Phone #

Inpatient ----- For Inpatient referrals, Please use CareLink.

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Referral Source
(CHECK ONE BELOW)

Physician Physician Assistant Nurse Nurse Practitioner

OccupationalTherapist Physical Therapist Social Worker

Respiratory Therapist Psychologist Other

Clinician Information:

First Name: L Last Name:

Pager # C Call Back #

Clinic/Service Name:

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Referral Notes :