Pediatric Referral Forms

If you have questions or are having access problems, please call the Dartmouth-Hitchcock Physician Connection Center.

Referral forms

• CHaD Pediatric Specialties Referral Form (PDF)
• Electroencephalography (EEG) and Evoked Potential Request Form (PDF)

Manchester Pediatric Neurology referral form

Referral forms are standard for all pediatric specialty services with the exception of sleep studies in Pediatric Neurology in Manchester. Please use the following specific form.

• CHaD Manchester Pediatric Neurology Referral Form (PDF)

Complex Primary Care Appointment/Transition of Care form

Visit the Dartmouth-Hitchcock Manchester Referrals page to download the Complex Primary Care Appointment/Transition of Care Request form.

Additional forms

For additional forms, visit the Referral Forms page on the Dartmouth-Hitchcock website.